|
MISC IMPLANTS/SUPPLY
|
Facility
|
IP
|
$9,053.00
|
|
| Hospital Charge Code |
3075880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,435.97 |
| Max. Negotiated Rate |
$8,328.76 |
| Rate for Payer: Aetna Commercial |
$8,147.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,785.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,798.09
|
| Rate for Payer: Cash Price |
$2,715.90
|
| Rate for Payer: Cigna Commercial |
$8,328.76
|
| Rate for Payer: Health EOS Commercial |
$8,057.17
|
| Rate for Payer: HFN Commercial |
$8,328.76
|
| Rate for Payer: Multiplan Commercial |
$7,242.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,431.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,328.76
|
| Rate for Payer: Quartz Beloit One Network |
$4,435.97
|
| Rate for Payer: Quartz Commercial |
$5,431.80
|
| Rate for Payer: WEA Trust Commercial |
$4,979.15
|
| Rate for Payer: WPS Commercial |
$6,705.56
|
|
|
Misc Lab Charge 99199
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$77.90 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.20
|
| Rate for Payer: Health EOS Commercial |
$74.62
|
| Rate for Payer: HFN Commercial |
$77.90
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: Preferred Network Access Commercial |
$77.90
|
| Rate for Payer: Quartz Beloit One Network |
$36.08
|
| Rate for Payer: Quartz Commercial |
$46.74
|
| Rate for Payer: The Alliance Commercial |
$41.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Misc Lab Charge 99199
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: United Healthcare PPO |
$61.50
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Misc Lab Charge 99199
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
MISC NON-STERILE SUPPLY
|
Facility
|
OP
|
$1,973.00
|
|
| Hospital Charge Code |
3075882
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$552.44 |
| Max. Negotiated Rate |
$7,892.00 |
| Rate for Payer: Aetna Commercial |
$1,775.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,696.78
|
| Rate for Payer: Aetna Managed Medicare |
$552.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,282.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$986.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$947.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,045.69
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,815.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,104.09
|
| Rate for Payer: Health EOS Commercial |
$1,755.97
|
| Rate for Payer: HFN Commercial |
$1,815.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,479.75
|
| Rate for Payer: Multiplan Commercial |
$1,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,183.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,815.16
|
| Rate for Payer: Quartz Beloit One Network |
$966.77
|
| Rate for Payer: Quartz Commercial |
$1,282.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,183.80
|
| Rate for Payer: The Alliance Commercial |
$7,892.00
|
| Rate for Payer: WEA Trust Commercial |
$1,085.15
|
| Rate for Payer: WPS Commercial |
$1,461.40
|
|
|
MISC NON-STERILE SUPPLY
|
Facility
|
IP
|
$1,973.00
|
|
| Hospital Charge Code |
3075882
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$966.77 |
| Max. Negotiated Rate |
$1,815.16 |
| Rate for Payer: Aetna Commercial |
$1,775.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,696.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,045.69
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,815.16
|
| Rate for Payer: Health EOS Commercial |
$1,755.97
|
| Rate for Payer: HFN Commercial |
$1,815.16
|
| Rate for Payer: Multiplan Commercial |
$1,578.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,183.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,815.16
|
| Rate for Payer: Quartz Beloit One Network |
$966.77
|
| Rate for Payer: Quartz Commercial |
$1,183.80
|
| Rate for Payer: WEA Trust Commercial |
$1,085.15
|
| Rate for Payer: WPS Commercial |
$1,461.40
|
|
|
MISC STERILE SUPPLY
|
Facility
|
OP
|
$7,738.00
|
|
| Hospital Charge Code |
3075881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,166.64 |
| Max. Negotiated Rate |
$30,952.00 |
| Rate for Payer: Aetna Commercial |
$6,964.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,654.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,166.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,029.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,714.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,101.14
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,118.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,330.18
|
| Rate for Payer: Health EOS Commercial |
$6,886.82
|
| Rate for Payer: HFN Commercial |
$7,118.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,803.50
|
| Rate for Payer: Multiplan Commercial |
$6,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,642.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,118.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,791.62
|
| Rate for Payer: Quartz Commercial |
$5,029.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,642.80
|
| Rate for Payer: The Alliance Commercial |
$30,952.00
|
| Rate for Payer: WEA Trust Commercial |
$4,255.90
|
| Rate for Payer: WPS Commercial |
$5,731.54
|
|
|
MISC STERILE SUPPLY
|
Facility
|
IP
|
$7,738.00
|
|
| Hospital Charge Code |
3075881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,791.62 |
| Max. Negotiated Rate |
$7,118.96 |
| Rate for Payer: Aetna Commercial |
$6,964.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,654.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,101.14
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,118.96
|
| Rate for Payer: Health EOS Commercial |
$6,886.82
|
| Rate for Payer: HFN Commercial |
$7,118.96
|
| Rate for Payer: Multiplan Commercial |
$6,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,642.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,118.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,791.62
|
| Rate for Payer: Quartz Commercial |
$4,642.80
|
| Rate for Payer: WEA Trust Commercial |
$4,255.90
|
| Rate for Payer: WPS Commercial |
$5,731.54
|
|
|
# Missed Attempt Femoral Artery
|
Facility
|
OP
|
$780.00
|
|
| Hospital Charge Code |
3811480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$702.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$670.80
|
| Rate for Payer: Aetna Managed Medicare |
$218.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$507.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$390.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$374.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$413.40
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$717.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$436.49
|
| Rate for Payer: Health EOS Commercial |
$694.20
|
| Rate for Payer: HFN Commercial |
$717.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$585.00
|
| Rate for Payer: Multiplan Commercial |
$624.00
|
| Rate for Payer: NAPHCARE Commercial |
$468.00
|
| Rate for Payer: Preferred Network Access Commercial |
$717.60
|
| Rate for Payer: Quartz Beloit One Network |
$382.20
|
| Rate for Payer: Quartz Commercial |
$507.00
|
| Rate for Payer: Quartz Medicare Advantage |
$468.00
|
| Rate for Payer: The Alliance Commercial |
$3,120.00
|
| Rate for Payer: WEA Trust Commercial |
$429.00
|
| Rate for Payer: WPS Commercial |
$577.75
|
|
|
# Missed Attempt Femoral Artery
|
Facility
|
IP
|
$780.00
|
|
| Hospital Charge Code |
3811480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$382.20 |
| Max. Negotiated Rate |
$717.60 |
| Rate for Payer: Aetna Commercial |
$702.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$670.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$413.40
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$717.60
|
| Rate for Payer: Health EOS Commercial |
$694.20
|
| Rate for Payer: HFN Commercial |
$717.60
|
| Rate for Payer: Multiplan Commercial |
$624.00
|
| Rate for Payer: NAPHCARE Commercial |
$468.00
|
| Rate for Payer: Preferred Network Access Commercial |
$717.60
|
| Rate for Payer: Quartz Beloit One Network |
$382.20
|
| Rate for Payer: Quartz Commercial |
$468.00
|
| Rate for Payer: WEA Trust Commercial |
$429.00
|
| Rate for Payer: WPS Commercial |
$577.75
|
|
|
# Missed Attempt Radial Artery
|
Facility
|
OP
|
$275.00
|
|
| Hospital Charge Code |
3811479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Aetna Managed Medicare |
$77.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.89
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$206.25
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$165.00
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$178.75
|
| Rate for Payer: Quartz Medicare Advantage |
$165.00
|
| Rate for Payer: The Alliance Commercial |
$1,100.00
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
# Missed Attempt Radial Artery
|
Facility
|
IP
|
$275.00
|
|
| Hospital Charge Code |
3811479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$134.75 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$165.00
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
.Mitochondrial Antibody Titer
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$203.30 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$203.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$128.40
|
| Rate for Payer: Health EOS Commercial |
$194.74
|
| Rate for Payer: HFN Commercial |
$203.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: Preferred Network Access Commercial |
$203.30
|
| Rate for Payer: Quartz Beloit One Network |
$94.16
|
| Rate for Payer: Quartz Commercial |
$121.98
|
| Rate for Payer: The Alliance Commercial |
$107.00
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
.Mitochondrial Antibody Titer
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.75
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$139.10
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$160.50
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
.Mitochondrial Antibody Titer
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.86 |
| Max. Negotiated Rate |
$196.88 |
| Rate for Payer: Aetna Commercial |
$192.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.42
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$196.88
|
| Rate for Payer: Health EOS Commercial |
$190.46
|
| Rate for Payer: HFN Commercial |
$196.88
|
| Rate for Payer: Multiplan Commercial |
$171.20
|
| Rate for Payer: NAPHCARE Commercial |
$128.40
|
| Rate for Payer: Preferred Network Access Commercial |
$196.88
|
| Rate for Payer: Quartz Beloit One Network |
$104.86
|
| Rate for Payer: Quartz Commercial |
$128.40
|
| Rate for Payer: WEA Trust Commercial |
$117.70
|
| Rate for Payer: WPS Commercial |
$158.51
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.61 |
| Max. Negotiated Rate |
$199.50 |
| Rate for Payer: Aetna Commercial |
$199.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Anthem Commercial |
$16.61
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$199.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.00
|
| Rate for Payer: Health EOS Commercial |
$191.10
|
| Rate for Payer: HFN Commercial |
$199.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.54
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: Preferred Network Access Commercial |
$199.50
|
| Rate for Payer: Quartz Beloit One Network |
$92.40
|
| Rate for Payer: Quartz Commercial |
$119.70
|
| Rate for Payer: The Alliance Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.45
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.52
|
| Rate for Payer: Dean Health Medicaid |
$12.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.45
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$136.50
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$157.50
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.45
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$193.20 |
| Rate for Payer: Aetna Commercial |
$189.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.30
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$193.20
|
| Rate for Payer: Health EOS Commercial |
$186.90
|
| Rate for Payer: HFN Commercial |
$193.20
|
| Rate for Payer: Multiplan Commercial |
$168.00
|
| Rate for Payer: NAPHCARE Commercial |
$126.00
|
| Rate for Payer: Preferred Network Access Commercial |
$193.20
|
| Rate for Payer: Quartz Beloit One Network |
$102.90
|
| Rate for Payer: Quartz Commercial |
$126.00
|
| Rate for Payer: WEA Trust Commercial |
$115.50
|
| Rate for Payer: WPS Commercial |
$155.55
|
|
|
Mitochondria M2 Antibody, IgG
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$69.08
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Mitochondria M2 Antibody, IgG
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.96 |
| Max. Negotiated Rate |
$338.20 |
| Rate for Payer: Aetna Commercial |
$338.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$338.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$178.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.60
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$338.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.20
|
| Rate for Payer: Quartz Beloit One Network |
$156.64
|
| Rate for Payer: Quartz Commercial |
$202.92
|
| Rate for Payer: The Alliance Commercial |
$178.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Mitochondria M2 Antibody, IgG
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$174.44 |
| Max. Negotiated Rate |
$327.52 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$188.68
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$327.52
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$213.60
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$213.60
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Mitomycin 5 MG inj J9280
|
Facility
|
OP
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$399.28 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Aetna Managed Medicare |
$63.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.32
|
| Rate for Payer: Anthem Medicare Advantage |
$63.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$63.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$63.35
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$63.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$63.35
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$235.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$63.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$63.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$63.35
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.02
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$282.10
|
| Rate for Payer: Quartz Medicare Advantage |
$63.35
|
| Rate for Payer: The Alliance Commercial |
$253.39
|
| Rate for Payer: United Healthcare Medicare Advantage |
$63.35
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: Wellcare Medicare |
$63.35
|
| Rate for Payer: WPS Commercial |
$167.58
|
|
|
Mitomycin 5 MG inj J9280
|
Professional
|
Both
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$62.43 |
| Max. Negotiated Rate |
$412.30 |
| Rate for Payer: Aetna Commercial |
$412.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$412.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$67.03
|
| Rate for Payer: Health EOS Commercial |
$394.94
|
| Rate for Payer: HFN Commercial |
$412.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.43
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: Preferred Network Access Commercial |
$412.30
|
| Rate for Payer: Quartz Beloit One Network |
$190.96
|
| Rate for Payer: Quartz Commercial |
$247.38
|
| Rate for Payer: The Alliance Commercial |
$217.00
|
| Rate for Payer: United Healthcare Medicaid |
$63.35
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$167.58
|
|
|
Mitomycin 5 MG inj J9280
|
Facility
|
IP
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.66 |
| Max. Negotiated Rate |
$399.28 |
| Rate for Payer: Aetna Commercial |
$390.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$373.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.02
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$399.28
|
| Rate for Payer: Health EOS Commercial |
$386.26
|
| Rate for Payer: HFN Commercial |
$399.28
|
| Rate for Payer: Multiplan Commercial |
$347.20
|
| Rate for Payer: NAPHCARE Commercial |
$260.40
|
| Rate for Payer: Preferred Network Access Commercial |
$399.28
|
| Rate for Payer: Quartz Beloit One Network |
$212.66
|
| Rate for Payer: Quartz Commercial |
$260.40
|
| Rate for Payer: WEA Trust Commercial |
$238.70
|
| Rate for Payer: WPS Commercial |
$321.46
|
|
|
MITRAL VALVE 25MM MOSAIC CINCH 310C25
|
Facility
|
IP
|
$38,439.00
|
|
| Hospital Charge Code |
2973958
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$18,835.11 |
| Max. Negotiated Rate |
$35,363.88 |
| Rate for Payer: Aetna Commercial |
$34,595.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$33,057.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20,372.67
|
| Rate for Payer: Cash Price |
$11,531.70
|
| Rate for Payer: Cigna Commercial |
$35,363.88
|
| Rate for Payer: Health EOS Commercial |
$34,210.71
|
| Rate for Payer: HFN Commercial |
$35,363.88
|
| Rate for Payer: Multiplan Commercial |
$30,751.20
|
| Rate for Payer: NAPHCARE Commercial |
$23,063.40
|
| Rate for Payer: Preferred Network Access Commercial |
$35,363.88
|
| Rate for Payer: Quartz Beloit One Network |
$18,835.11
|
| Rate for Payer: Quartz Commercial |
$23,063.40
|
| Rate for Payer: WEA Trust Commercial |
$21,141.45
|
| Rate for Payer: WPS Commercial |
$28,471.77
|
|
