|
Menveo Vaccine 90734
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.68 |
| Max. Negotiated Rate |
$1,624.00 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$113.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$203.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.50
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$243.60
|
| Rate for Payer: The Alliance Commercial |
$1,624.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Menveo Vaccine 90734
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Menveo Vaccine 90734VFC
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$224.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$224.10
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$163.49
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
Menveo Vaccine 90734VFC
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
Menveo Vaccine 90734VFC
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90734
|
| Hospital Charge Code |
5577614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.83 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$5.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.62
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$12.50
|
| Rate for Payer: The Alliance Commercial |
$83.32
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
meperidine 50 mg/mL Syr [Med]
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2983115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.13
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$17.25
|
|
|
meperidine 50 mg/mL Syr [Med]
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
2983115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$17.25 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.90
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$9.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.37
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$6.90
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$17.25
|
|
|
Meperidine hydrochl/100 mg J2175 man
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
3373625
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.13
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$17.25
|
|
|
MEPILEX 4X10 BORDER AG DRESSING 498450"
|
Facility
|
IP
|
$887.00
|
|
| Hospital Charge Code |
2963577
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$434.63 |
| Max. Negotiated Rate |
$816.04 |
| Rate for Payer: Aetna Commercial |
$798.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.11
|
| Rate for Payer: Cash Price |
$266.10
|
| Rate for Payer: Cigna Commercial |
$816.04
|
| Rate for Payer: Health EOS Commercial |
$789.43
|
| Rate for Payer: HFN Commercial |
$816.04
|
| Rate for Payer: Multiplan Commercial |
$709.60
|
| Rate for Payer: NAPHCARE Commercial |
$532.20
|
| Rate for Payer: Preferred Network Access Commercial |
$816.04
|
| Rate for Payer: Quartz Beloit One Network |
$434.63
|
| Rate for Payer: Quartz Commercial |
$532.20
|
| Rate for Payer: WEA Trust Commercial |
$487.85
|
| Rate for Payer: WPS Commercial |
$657.00
|
|
|
MEPILEX 4X10 BORDER AG DRESSING 498450"
|
Facility
|
OP
|
$887.00
|
|
| Hospital Charge Code |
2963577
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.36 |
| Max. Negotiated Rate |
$3,548.00 |
| Rate for Payer: Aetna Commercial |
$798.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$762.82
|
| Rate for Payer: Aetna Managed Medicare |
$248.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$576.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$443.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$425.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.11
|
| Rate for Payer: Cash Price |
$266.10
|
| Rate for Payer: Cigna Commercial |
$816.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$496.37
|
| Rate for Payer: Health EOS Commercial |
$789.43
|
| Rate for Payer: HFN Commercial |
$816.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$665.25
|
| Rate for Payer: Multiplan Commercial |
$709.60
|
| Rate for Payer: NAPHCARE Commercial |
$532.20
|
| Rate for Payer: Preferred Network Access Commercial |
$816.04
|
| Rate for Payer: Quartz Beloit One Network |
$434.63
|
| Rate for Payer: Quartz Commercial |
$576.55
|
| Rate for Payer: Quartz Medicare Advantage |
$532.20
|
| Rate for Payer: The Alliance Commercial |
$3,548.00
|
| Rate for Payer: WEA Trust Commercial |
$487.85
|
| Rate for Payer: WPS Commercial |
$657.00
|
|
|
MEPILEX 4X14 BORDER AG DRESSING 498650"
|
Facility
|
OP
|
$988.00
|
|
| Hospital Charge Code |
2963552
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$276.64 |
| Max. Negotiated Rate |
$3,952.00 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Aetna Managed Medicare |
$276.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$642.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$494.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$474.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$552.88
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$741.00
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$642.20
|
| Rate for Payer: Quartz Medicare Advantage |
$592.80
|
| Rate for Payer: The Alliance Commercial |
$3,952.00
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
MEPILEX 4X14 BORDER AG DRESSING 498650"
|
Facility
|
IP
|
$988.00
|
|
| Hospital Charge Code |
2963552
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$484.12 |
| Max. Negotiated Rate |
$908.96 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$849.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$523.64
|
| Rate for Payer: Cash Price |
$296.40
|
| Rate for Payer: Cigna Commercial |
$908.96
|
| Rate for Payer: Health EOS Commercial |
$879.32
|
| Rate for Payer: HFN Commercial |
$908.96
|
| Rate for Payer: Multiplan Commercial |
$790.40
|
| Rate for Payer: NAPHCARE Commercial |
$592.80
|
| Rate for Payer: Preferred Network Access Commercial |
$908.96
|
| Rate for Payer: Quartz Beloit One Network |
$484.12
|
| Rate for Payer: Quartz Commercial |
$592.80
|
| Rate for Payer: WEA Trust Commercial |
$543.40
|
| Rate for Payer: WPS Commercial |
$731.81
|
|
|
MEPILEX 4X6 BORDER AG DRESSING 498300"
|
Facility
|
IP
|
$709.00
|
|
| Hospital Charge Code |
2963646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$347.41 |
| Max. Negotiated Rate |
$652.28 |
| Rate for Payer: Aetna Commercial |
$638.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.77
|
| Rate for Payer: Cash Price |
$212.70
|
| Rate for Payer: Cigna Commercial |
$652.28
|
| Rate for Payer: Health EOS Commercial |
$631.01
|
| Rate for Payer: HFN Commercial |
$652.28
|
| Rate for Payer: Multiplan Commercial |
$567.20
|
| Rate for Payer: NAPHCARE Commercial |
$425.40
|
| Rate for Payer: Preferred Network Access Commercial |
$652.28
|
| Rate for Payer: Quartz Beloit One Network |
$347.41
|
| Rate for Payer: Quartz Commercial |
$425.40
|
| Rate for Payer: WEA Trust Commercial |
$389.95
|
| Rate for Payer: WPS Commercial |
$525.16
|
|
|
MEPILEX 4X6 BORDER AG DRESSING 498300"
|
Facility
|
OP
|
$709.00
|
|
| Hospital Charge Code |
2963646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$198.52 |
| Max. Negotiated Rate |
$2,836.00 |
| Rate for Payer: Aetna Commercial |
$638.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$609.74
|
| Rate for Payer: Aetna Managed Medicare |
$198.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$460.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$354.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$340.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$375.77
|
| Rate for Payer: Cash Price |
$212.70
|
| Rate for Payer: Cigna Commercial |
$652.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$396.76
|
| Rate for Payer: Health EOS Commercial |
$631.01
|
| Rate for Payer: HFN Commercial |
$652.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$531.75
|
| Rate for Payer: Multiplan Commercial |
$567.20
|
| Rate for Payer: NAPHCARE Commercial |
$425.40
|
| Rate for Payer: Preferred Network Access Commercial |
$652.28
|
| Rate for Payer: Quartz Beloit One Network |
$347.41
|
| Rate for Payer: Quartz Commercial |
$460.85
|
| Rate for Payer: Quartz Medicare Advantage |
$425.40
|
| Rate for Payer: The Alliance Commercial |
$2,836.00
|
| Rate for Payer: WEA Trust Commercial |
$389.95
|
| Rate for Payer: WPS Commercial |
$525.16
|
|
|
Mercury Level
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
978013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Aetna Managed Medicare |
$16.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.99
|
| Rate for Payer: Anthem Medicaid |
$16.80
|
| Rate for Payer: Anthem Medicare Advantage |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.26
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.53
|
| Rate for Payer: Dean Health Medicaid |
$16.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.26
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.26
|
| Rate for Payer: Managed Health Services Medicaid |
$17.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.26
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$24.39
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.80
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$174.85
|
| Rate for Payer: Quartz Medicare Advantage |
$16.26
|
| Rate for Payer: The Alliance Commercial |
$65.04
|
| Rate for Payer: United Healthcare Medicaid |
$16.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.26
|
| Rate for Payer: United Healthcare PPO |
$201.75
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: Wellcare Medicare |
$16.26
|
| Rate for Payer: WMAP Medicaid |
$16.80
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Mercury Level
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
2942905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Mercury Level
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
978013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$247.48 |
| Rate for Payer: Aetna Commercial |
$242.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.57
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$247.48
|
| Rate for Payer: Health EOS Commercial |
$239.41
|
| Rate for Payer: HFN Commercial |
$247.48
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: NAPHCARE Commercial |
$161.40
|
| Rate for Payer: Preferred Network Access Commercial |
$247.48
|
| Rate for Payer: Quartz Beloit One Network |
$131.81
|
| Rate for Payer: Quartz Commercial |
$161.40
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Mercury Level
|
Professional
|
Both
|
$269.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
978013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$255.55 |
| Rate for Payer: Aetna Commercial |
$255.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$231.34
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cash Price |
$80.70
|
| Rate for Payer: Cigna Commercial |
$255.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$161.40
|
| Rate for Payer: Health EOS Commercial |
$244.79
|
| Rate for Payer: HFN Commercial |
$255.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$215.20
|
| Rate for Payer: Preferred Network Access Commercial |
$255.55
|
| Rate for Payer: Quartz Beloit One Network |
$118.36
|
| Rate for Payer: Quartz Commercial |
$153.33
|
| Rate for Payer: The Alliance Commercial |
$134.50
|
| Rate for Payer: WEA Trust Commercial |
$147.95
|
| Rate for Payer: WPS Commercial |
$199.25
|
|
|
Mercury Level
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
2942905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.40 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$143.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.60
|
| Rate for Payer: Health EOS Commercial |
$260.26
|
| Rate for Payer: HFN Commercial |
$271.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: Preferred Network Access Commercial |
$271.70
|
| Rate for Payer: Quartz Beloit One Network |
$125.84
|
| Rate for Payer: Quartz Commercial |
$163.02
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Mercury Level
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
2942905
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$16.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.99
|
| Rate for Payer: Anthem Medicaid |
$16.80
|
| Rate for Payer: Anthem Medicare Advantage |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.26
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Dean Health Medicaid |
$16.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.26
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.26
|
| Rate for Payer: Managed Health Services Medicaid |
$17.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.26
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$24.39
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.80
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$16.26
|
| Rate for Payer: The Alliance Commercial |
$65.04
|
| Rate for Payer: United Healthcare Medicaid |
$16.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.26
|
| Rate for Payer: United Healthcare PPO |
$214.50
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: Wellcare Medicare |
$16.26
|
| Rate for Payer: WMAP Medicaid |
$16.80
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Mercury, Urine
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
5364646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Mercury, Urine
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
5364646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$57.40 |
| Rate for Payer: Aetna Commercial |
$45.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.80
|
| Rate for Payer: Health EOS Commercial |
$43.68
|
| Rate for Payer: HFN Commercial |
$45.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.40
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.60
|
| Rate for Payer: Quartz Beloit One Network |
$21.12
|
| Rate for Payer: Quartz Commercial |
$27.36
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
Mercury, Urine
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
5364646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$65.04 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$16.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.46
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.99
|
| Rate for Payer: Anthem Medicaid |
$16.80
|
| Rate for Payer: Anthem Medicare Advantage |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.26
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Dean Health Medicaid |
$16.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.26
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.26
|
| Rate for Payer: Managed Health Services Medicaid |
$17.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.26
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$24.39
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.80
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.26
|
| Rate for Payer: The Alliance Commercial |
$65.04
|
| Rate for Payer: United Healthcare Medicaid |
$16.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.26
|
| Rate for Payer: United Healthcare PPO |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: Wellcare Medicare |
$16.26
|
| Rate for Payer: WMAP Medicaid |
$16.80
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
