|
MISC IMPLANTS/SUPPLY
|
Facility
|
OP
|
$9,053.00
|
|
| Hospital Charge Code |
3075880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,636.23 |
| Max. Negotiated Rate |
$8,661.91 |
| Rate for Payer: Aetna Commercial |
$8,473.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,097.00
|
| Rate for Payer: Aetna Managed Medicare |
$2,636.23
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,119.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,707.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,519.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,990.01
|
| Rate for Payer: Cash Price |
$2,715.90
|
| Rate for Payer: Cigna Commercial |
$8,661.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,268.85
|
| Rate for Payer: Health EOS Commercial |
$8,379.46
|
| Rate for Payer: HFN Commercial |
$8,661.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,061.34
|
| Rate for Payer: Multiplan Commercial |
$7,532.10
|
| Rate for Payer: NAPHCARE Commercial |
$5,649.07
|
| Rate for Payer: Preferred Network Access Commercial |
$8,661.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,613.41
|
| Rate for Payer: Quartz Commercial |
$6,119.83
|
| Rate for Payer: Quartz Medicare Advantage |
$5,649.07
|
| Rate for Payer: The Alliance Commercial |
$4,707.56
|
| Rate for Payer: WEA Trust Commercial |
$5,178.32
|
| Rate for Payer: WPS Commercial |
$6,973.53
|
|
|
MISC IMPLANTS/SUPPLY
|
Facility
|
IP
|
$9,053.00
|
|
| Hospital Charge Code |
3075880
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,613.41 |
| Max. Negotiated Rate |
$8,661.91 |
| Rate for Payer: Aetna Commercial |
$8,473.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,097.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,990.01
|
| Rate for Payer: Cash Price |
$2,715.90
|
| Rate for Payer: Cigna Commercial |
$8,661.91
|
| Rate for Payer: Health EOS Commercial |
$8,379.46
|
| Rate for Payer: HFN Commercial |
$8,661.91
|
| Rate for Payer: Multiplan Commercial |
$7,532.10
|
| Rate for Payer: Preferred Network Access Commercial |
$8,661.91
|
| Rate for Payer: Quartz Beloit One Network |
$4,613.41
|
| Rate for Payer: Quartz Commercial |
$5,649.07
|
| Rate for Payer: WEA Trust Commercial |
$5,178.32
|
| Rate for Payer: WPS Commercial |
$6,973.53
|
|
|
Misc Lab Charge 99199
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.79 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$51.17
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Misc Lab Charge 99199
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$78.46 |
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Aetna Managed Medicare |
$23.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.20
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$78.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.72
|
| Rate for Payer: Health EOS Commercial |
$75.90
|
| Rate for Payer: HFN Commercial |
$78.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.96
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: NAPHCARE Commercial |
$51.17
|
| Rate for Payer: Preferred Network Access Commercial |
$78.46
|
| Rate for Payer: Quartz Beloit One Network |
$41.79
|
| Rate for Payer: Quartz Commercial |
$55.43
|
| Rate for Payer: Quartz Medicare Advantage |
$51.17
|
| Rate for Payer: The Alliance Commercial |
$42.64
|
| Rate for Payer: United Healthcare PPO |
$63.96
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
Misc Lab Charge 99199
|
Professional
|
Both
|
$82.00
|
|
|
Service Code
|
CPT 99199
|
| Hospital Charge Code |
3219513
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.52 |
| Max. Negotiated Rate |
$81.02 |
| Rate for Payer: Aetna Commercial |
$81.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$73.34
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$81.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.17
|
| Rate for Payer: Health EOS Commercial |
$77.60
|
| Rate for Payer: HFN Commercial |
$81.02
|
| Rate for Payer: Multiplan Commercial |
$68.22
|
| Rate for Payer: Preferred Network Access Commercial |
$81.02
|
| Rate for Payer: Quartz Beloit One Network |
$37.52
|
| Rate for Payer: Quartz Commercial |
$48.61
|
| Rate for Payer: The Alliance Commercial |
$42.64
|
| Rate for Payer: WEA Trust Commercial |
$46.90
|
| Rate for Payer: WPS Commercial |
$63.16
|
|
|
MISC NON-STERILE SUPPLY
|
Facility
|
IP
|
$1,973.00
|
|
| Hospital Charge Code |
3075882
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,005.44 |
| Max. Negotiated Rate |
$1,887.77 |
| Rate for Payer: Aetna Commercial |
$1,846.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,764.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,087.52
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,887.77
|
| Rate for Payer: Health EOS Commercial |
$1,826.21
|
| Rate for Payer: HFN Commercial |
$1,887.77
|
| Rate for Payer: Multiplan Commercial |
$1,641.54
|
| Rate for Payer: Preferred Network Access Commercial |
$1,887.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,005.44
|
| Rate for Payer: Quartz Commercial |
$1,231.15
|
| Rate for Payer: WEA Trust Commercial |
$1,128.56
|
| Rate for Payer: WPS Commercial |
$1,519.80
|
|
|
MISC NON-STERILE SUPPLY
|
Facility
|
OP
|
$1,973.00
|
|
| Hospital Charge Code |
3075882
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$574.54 |
| Max. Negotiated Rate |
$1,887.77 |
| Rate for Payer: Aetna Commercial |
$1,846.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,764.65
|
| Rate for Payer: Aetna Managed Medicare |
$574.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,333.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,025.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$984.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,087.52
|
| Rate for Payer: Cash Price |
$591.90
|
| Rate for Payer: Cigna Commercial |
$1,887.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,148.29
|
| Rate for Payer: Health EOS Commercial |
$1,826.21
|
| Rate for Payer: HFN Commercial |
$1,887.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,538.94
|
| Rate for Payer: Multiplan Commercial |
$1,641.54
|
| Rate for Payer: NAPHCARE Commercial |
$1,231.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,887.77
|
| Rate for Payer: Quartz Beloit One Network |
$1,005.44
|
| Rate for Payer: Quartz Commercial |
$1,333.75
|
| Rate for Payer: Quartz Medicare Advantage |
$1,231.15
|
| Rate for Payer: The Alliance Commercial |
$1,025.96
|
| Rate for Payer: WEA Trust Commercial |
$1,128.56
|
| Rate for Payer: WPS Commercial |
$1,519.80
|
|
|
MISC STERILE SUPPLY
|
Facility
|
IP
|
$7,738.00
|
|
| Hospital Charge Code |
3075881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,943.28 |
| Max. Negotiated Rate |
$7,403.72 |
| Rate for Payer: Aetna Commercial |
$7,242.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,920.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,265.19
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,403.72
|
| Rate for Payer: Health EOS Commercial |
$7,162.29
|
| Rate for Payer: HFN Commercial |
$7,403.72
|
| Rate for Payer: Multiplan Commercial |
$6,438.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,403.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,943.28
|
| Rate for Payer: Quartz Commercial |
$4,828.51
|
| Rate for Payer: WEA Trust Commercial |
$4,426.14
|
| Rate for Payer: WPS Commercial |
$5,960.58
|
|
|
MISC STERILE SUPPLY
|
Facility
|
OP
|
$7,738.00
|
|
| Hospital Charge Code |
3075881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,253.31 |
| Max. Negotiated Rate |
$7,403.72 |
| Rate for Payer: Aetna Commercial |
$7,242.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,920.87
|
| Rate for Payer: Aetna Managed Medicare |
$2,253.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,230.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,023.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,862.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,265.19
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,403.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,503.52
|
| Rate for Payer: Health EOS Commercial |
$7,162.29
|
| Rate for Payer: HFN Commercial |
$7,403.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,035.64
|
| Rate for Payer: Multiplan Commercial |
$6,438.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,828.51
|
| Rate for Payer: Preferred Network Access Commercial |
$7,403.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,943.28
|
| Rate for Payer: Quartz Commercial |
$5,230.89
|
| Rate for Payer: Quartz Medicare Advantage |
$4,828.51
|
| Rate for Payer: The Alliance Commercial |
$4,023.76
|
| Rate for Payer: WEA Trust Commercial |
$4,426.14
|
| Rate for Payer: WPS Commercial |
$5,960.58
|
|
|
# Missed Attempt Femoral Artery
|
Facility
|
OP
|
$780.00
|
|
| Hospital Charge Code |
3811480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.14 |
| Max. Negotiated Rate |
$746.30 |
| Rate for Payer: Aetna Commercial |
$730.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.63
|
| Rate for Payer: Aetna Managed Medicare |
$227.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$527.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$405.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$389.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.94
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$746.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$453.96
|
| Rate for Payer: Health EOS Commercial |
$721.97
|
| Rate for Payer: HFN Commercial |
$746.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$608.40
|
| Rate for Payer: Multiplan Commercial |
$648.96
|
| Rate for Payer: NAPHCARE Commercial |
$486.72
|
| Rate for Payer: Preferred Network Access Commercial |
$746.30
|
| Rate for Payer: Quartz Beloit One Network |
$397.49
|
| Rate for Payer: Quartz Commercial |
$527.28
|
| Rate for Payer: Quartz Medicare Advantage |
$486.72
|
| Rate for Payer: The Alliance Commercial |
$405.60
|
| Rate for Payer: WEA Trust Commercial |
$446.16
|
| Rate for Payer: WPS Commercial |
$600.83
|
|
|
# Missed Attempt Femoral Artery
|
Facility
|
IP
|
$780.00
|
|
| Hospital Charge Code |
3811480
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$397.49 |
| Max. Negotiated Rate |
$746.30 |
| Rate for Payer: Aetna Commercial |
$730.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.94
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$746.30
|
| Rate for Payer: Health EOS Commercial |
$721.97
|
| Rate for Payer: HFN Commercial |
$746.30
|
| Rate for Payer: Multiplan Commercial |
$648.96
|
| Rate for Payer: Preferred Network Access Commercial |
$746.30
|
| Rate for Payer: Quartz Beloit One Network |
$397.49
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: WEA Trust Commercial |
$446.16
|
| Rate for Payer: WPS Commercial |
$600.83
|
|
|
# Missed Attempt Radial Artery
|
Facility
|
IP
|
$275.00
|
|
| Hospital Charge Code |
3811479
|
|
Hospital Revenue Code
|
272
|
| 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 |
$82.50
|
| 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: 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 |
$211.83
|
|
|
# Missed Attempt Radial Artery
|
Facility
|
OP
|
$275.00
|
|
| Hospital Charge Code |
3811479
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$80.08 |
| 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 |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.05
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| 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 |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.83
|
|
|
.Mitochondrial Antibody Titer
|
Facility
|
IP
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$109.05 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$133.54
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
.Mitochondrial Antibody Titer
|
Facility
|
OP
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$204.76 |
| Rate for Payer: Aetna Commercial |
$200.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$117.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$204.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$198.08
|
| Rate for Payer: HFN Commercial |
$204.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$204.76
|
| Rate for Payer: Quartz Beloit One Network |
$109.05
|
| Rate for Payer: Quartz Commercial |
$144.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$164.84
|
|
|
.Mitochondrial Antibody Titer
|
Professional
|
Both
|
$214.00
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
1037518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$211.43 |
| Rate for Payer: Aetna Commercial |
$211.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.40
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cash Price |
$64.20
|
| Rate for Payer: Cigna Commercial |
$211.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$111.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$202.53
|
| Rate for Payer: HFN Commercial |
$211.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$178.05
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$211.43
|
| Rate for Payer: Quartz Beloit One Network |
$97.93
|
| Rate for Payer: Quartz Commercial |
$126.86
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$122.41
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.02 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$131.04
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$196.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$200.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$122.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$194.38
|
| Rate for Payer: HFN Commercial |
$200.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$200.93
|
| Rate for Payer: Quartz Beloit One Network |
$107.02
|
| Rate for Payer: Quartz Commercial |
$141.96
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$163.80
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$161.76
|
|
|
Mitochondrial Antibody w/ Rfx Titer
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
983328
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$207.48 |
| Rate for Payer: Aetna Commercial |
$207.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.82
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cash Price |
$63.00
|
| Rate for Payer: Cigna Commercial |
$207.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$198.74
|
| Rate for Payer: HFN Commercial |
$207.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$174.72
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$207.48
|
| Rate for Payer: Quartz Beloit One Network |
$96.10
|
| Rate for Payer: Quartz Commercial |
$124.49
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$120.12
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
Mitochondria M2 Antibody, IgG
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Mitochondria M2 Antibody, IgG
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$351.73 |
| Rate for Payer: Aetna Commercial |
$351.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$351.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$351.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$351.73
|
| Rate for Payer: Quartz Beloit One Network |
$162.91
|
| Rate for Payer: Quartz Commercial |
$211.04
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Mitochondria M2 Antibody, IgG
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
983327
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Mitomycin 5 MG inj J9280
|
Professional
|
Both
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$428.79 |
| Rate for Payer: Aetna Commercial |
$428.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Aetna Managed Medicare |
$27.14
|
| Rate for Payer: Anthem Medicare Advantage |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.14
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$428.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.71
|
| Rate for Payer: Health EOS Commercial |
$410.74
|
| Rate for Payer: HFN Commercial |
$428.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.14
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: NAPHCARE Commercial |
$40.72
|
| Rate for Payer: Preferred Network Access Commercial |
$428.79
|
| Rate for Payer: Quartz Beloit One Network |
$198.60
|
| Rate for Payer: Quartz Commercial |
$257.28
|
| Rate for Payer: Quartz Medicare Advantage |
$27.14
|
| Rate for Payer: The Alliance Commercial |
$74.65
|
| Rate for Payer: United Healthcare Medicaid |
$27.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.14
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$174.28
|
|
|
Mitomycin 5 MG inj J9280
|
Facility
|
OP
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.14 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Aetna Managed Medicare |
$27.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$293.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$225.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$216.65
|
| Rate for Payer: Anthem Medicare Advantage |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$27.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$27.14
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$27.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$92.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$27.14
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$27.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$27.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$27.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$27.14
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: NAPHCARE Commercial |
$40.72
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$293.38
|
| Rate for Payer: Quartz Medicare Advantage |
$27.14
|
| Rate for Payer: The Alliance Commercial |
$108.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$27.14
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: Wellcare Medicare |
$27.14
|
| Rate for Payer: WPS Commercial |
$174.28
|
|
|
Mitomycin 5 MG inj J9280
|
Facility
|
IP
|
$434.00
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
3873518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$221.17 |
| Max. Negotiated Rate |
$415.25 |
| Rate for Payer: Aetna Commercial |
$406.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$239.22
|
| Rate for Payer: Cash Price |
$130.20
|
| Rate for Payer: Cigna Commercial |
$415.25
|
| Rate for Payer: Health EOS Commercial |
$401.71
|
| Rate for Payer: HFN Commercial |
$415.25
|
| Rate for Payer: Multiplan Commercial |
$361.09
|
| Rate for Payer: Preferred Network Access Commercial |
$415.25
|
| Rate for Payer: Quartz Beloit One Network |
$221.17
|
| Rate for Payer: Quartz Commercial |
$270.82
|
| Rate for Payer: WEA Trust Commercial |
$248.25
|
| Rate for Payer: WPS Commercial |
$334.31
|
|
