|
MTHFR DNA Mutation Analysis
|
Facility
|
OP
|
$1,304.00
|
|
|
Service Code
|
CPT 81291
|
| Hospital Charge Code |
983331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.34 |
| Max. Negotiated Rate |
$1,199.68 |
| Rate for Payer: Aetna Commercial |
$1,173.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Aetna Managed Medicare |
$65.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$245.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$114.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$108.46
|
| Rate for Payer: Anthem Medicare Advantage |
$65.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$691.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$65.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$65.34
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,199.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$65.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$729.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$65.34
|
| Rate for Payer: Health EOS Commercial |
$1,160.56
|
| Rate for Payer: HFN Commercial |
$1,199.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$243.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$65.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$65.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$65.34
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: NAPHCARE Commercial |
$98.01
|
| Rate for Payer: Preferred Network Access Commercial |
$1,199.68
|
| Rate for Payer: Quartz Beloit One Network |
$638.96
|
| Rate for Payer: Quartz Commercial |
$847.60
|
| Rate for Payer: Quartz Medicare Advantage |
$65.34
|
| Rate for Payer: The Alliance Commercial |
$261.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$65.34
|
| Rate for Payer: United Healthcare PPO |
$978.00
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: Wellcare Medicare |
$65.34
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
MTHFR DNA Mutation Analysis
|
Professional
|
Both
|
$1,304.00
|
|
|
Service Code
|
CPT 81291
|
| Hospital Charge Code |
983331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$230.65 |
| Max. Negotiated Rate |
$1,238.80 |
| Rate for Payer: Aetna Commercial |
$1,238.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,121.44
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cash Price |
$391.20
|
| Rate for Payer: Cigna Commercial |
$1,238.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$652.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$782.40
|
| Rate for Payer: Health EOS Commercial |
$1,186.64
|
| Rate for Payer: HFN Commercial |
$1,238.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$230.65
|
| Rate for Payer: Multiplan Commercial |
$1,043.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,238.80
|
| Rate for Payer: Quartz Beloit One Network |
$573.76
|
| Rate for Payer: Quartz Commercial |
$743.28
|
| Rate for Payer: The Alliance Commercial |
$652.00
|
| Rate for Payer: WEA Trust Commercial |
$717.20
|
| Rate for Payer: WPS Commercial |
$965.87
|
|
|
MTHFR Nucleic Acid Probe
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2778801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
MTHFR Nucleic Acid Probe
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2778801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
MTHFR Nucleic Acid Probe
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2778801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
MUELLER GEL BRACE COLD THERAPY
|
Facility
|
OP
|
$435.00
|
|
| Hospital Charge Code |
2971128
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna Commercial |
$391.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$374.10
|
| Rate for Payer: Aetna Managed Medicare |
$121.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$282.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$217.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$208.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.55
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$400.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.43
|
| Rate for Payer: Health EOS Commercial |
$387.15
|
| Rate for Payer: HFN Commercial |
$400.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$326.25
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
| Rate for Payer: NAPHCARE Commercial |
$261.00
|
| Rate for Payer: Preferred Network Access Commercial |
$400.20
|
| Rate for Payer: Quartz Beloit One Network |
$213.15
|
| Rate for Payer: Quartz Commercial |
$282.75
|
| Rate for Payer: Quartz Medicare Advantage |
$261.00
|
| Rate for Payer: The Alliance Commercial |
$1,740.00
|
| Rate for Payer: WEA Trust Commercial |
$239.25
|
| Rate for Payer: WPS Commercial |
$322.20
|
|
|
MUELLER GEL BRACE COLD THERAPY
|
Facility
|
IP
|
$435.00
|
|
| Hospital Charge Code |
2971128
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$213.15 |
| Max. Negotiated Rate |
$400.20 |
| Rate for Payer: Aetna Commercial |
$391.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$374.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$230.55
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$400.20
|
| Rate for Payer: Health EOS Commercial |
$387.15
|
| Rate for Payer: HFN Commercial |
$400.20
|
| Rate for Payer: Multiplan Commercial |
$348.00
|
| Rate for Payer: NAPHCARE Commercial |
$261.00
|
| Rate for Payer: Preferred Network Access Commercial |
$400.20
|
| Rate for Payer: Quartz Beloit One Network |
$213.15
|
| Rate for Payer: Quartz Commercial |
$261.00
|
| Rate for Payer: WEA Trust Commercial |
$239.25
|
| Rate for Payer: WPS Commercial |
$322.20
|
|
|
Multi Den Insert Custom Med A5513
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
HCPCS A5513
|
| Hospital Charge Code |
5290775
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$21.56 |
| Max. Negotiated Rate |
$159.03 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.40
|
| Rate for Payer: Health EOS Commercial |
$44.59
|
| Rate for Payer: HFN Commercial |
$46.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$159.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$159.03
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: Preferred Network Access Commercial |
$46.55
|
| Rate for Payer: Quartz Beloit One Network |
$21.56
|
| Rate for Payer: Quartz Commercial |
$27.93
|
| Rate for Payer: The Alliance Commercial |
$24.50
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Multi Den Insert Custom Med A5513
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
HCPCS A5513
|
| Hospital Charge Code |
5290775
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Multi Den Insert Custom Med A5513
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
HCPCS A5513
|
| Hospital Charge Code |
5290775
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Multi den insert direct form A5512
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS A5512
|
| Hospital Charge Code |
3133662
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Multi den insert direct form A5512
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS A5512
|
| Hospital Charge Code |
3133662
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Multi den insert direct form A5512
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS A5512
|
| Hospital Charge Code |
3133662
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$106.57 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.00
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.57
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Multihance 10 ml
|
Professional
|
Both
|
$258.00
|
|
| Hospital Charge Code |
1486806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.52 |
| Max. Negotiated Rate |
$245.10 |
| Rate for Payer: Aetna Commercial |
$245.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$245.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.80
|
| Rate for Payer: Health EOS Commercial |
$234.78
|
| Rate for Payer: HFN Commercial |
$245.10
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$245.10
|
| Rate for Payer: Quartz Beloit One Network |
$113.52
|
| Rate for Payer: Quartz Commercial |
$147.06
|
| Rate for Payer: The Alliance Commercial |
$129.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Multihance 10 ml
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
1486806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.24 |
| Max. Negotiated Rate |
$1,032.00 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Aetna Managed Medicare |
$72.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$129.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.38
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.50
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$167.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.80
|
| Rate for Payer: The Alliance Commercial |
$1,032.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Multihance 10 ml
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
1486806
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.42 |
| Max. Negotiated Rate |
$237.36 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Multihance 15 ml
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
1486808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$340.40 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Multihance 15 ml
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
1486808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$1,480.00 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.05
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$240.50
|
| Rate for Payer: Quartz Medicare Advantage |
$222.00
|
| Rate for Payer: The Alliance Commercial |
$1,480.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Multihance 15 ml
|
Professional
|
Both
|
$370.00
|
|
| Hospital Charge Code |
1486808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.80 |
| Max. Negotiated Rate |
$351.50 |
| Rate for Payer: Aetna Commercial |
$351.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$351.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.00
|
| Rate for Payer: Health EOS Commercial |
$336.70
|
| Rate for Payer: HFN Commercial |
$351.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: Preferred Network Access Commercial |
$351.50
|
| Rate for Payer: Quartz Beloit One Network |
$162.80
|
| Rate for Payer: Quartz Commercial |
$210.90
|
| Rate for Payer: The Alliance Commercial |
$185.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Multihance 20 ml
|
Facility
|
IP
|
$482.00
|
|
| Hospital Charge Code |
1486810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.18 |
| Max. Negotiated Rate |
$443.44 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$289.20
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Multihance 20 ml
|
Facility
|
OP
|
$482.00
|
|
| Hospital Charge Code |
1486810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.96 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Aetna Managed Medicare |
$134.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$313.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$241.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.73
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.50
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$313.30
|
| Rate for Payer: Quartz Medicare Advantage |
$289.20
|
| Rate for Payer: The Alliance Commercial |
$1,928.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Multihance 20 ml
|
Professional
|
Both
|
$482.00
|
|
| Hospital Charge Code |
1486810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.08 |
| Max. Negotiated Rate |
$457.90 |
| Rate for Payer: Aetna Commercial |
$457.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$457.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.20
|
| Rate for Payer: Health EOS Commercial |
$438.62
|
| Rate for Payer: HFN Commercial |
$457.90
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: Preferred Network Access Commercial |
$457.90
|
| Rate for Payer: Quartz Beloit One Network |
$212.08
|
| Rate for Payer: Quartz Commercial |
$274.74
|
| Rate for Payer: The Alliance Commercial |
$241.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Multi-Leaf Design 7733826
|
Professional
|
Both
|
$2,357.00
|
|
|
Service Code
|
CPT 77338 26
|
| Hospital Charge Code |
5258641
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$771.73 |
| Max. Negotiated Rate |
$2,239.15 |
| Rate for Payer: Aetna Commercial |
$2,239.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,027.02
|
| Rate for Payer: Cash Price |
$707.10
|
| Rate for Payer: Cash Price |
$707.10
|
| Rate for Payer: Cash Price |
$707.10
|
| Rate for Payer: Cigna Commercial |
$2,239.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,178.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,414.20
|
| Rate for Payer: Health EOS Commercial |
$2,144.87
|
| Rate for Payer: HFN Commercial |
$2,239.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$771.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$771.73
|
| Rate for Payer: Multiplan Commercial |
$1,885.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,239.15
|
| Rate for Payer: Quartz Beloit One Network |
$1,037.08
|
| Rate for Payer: Quartz Commercial |
$1,343.49
|
| Rate for Payer: The Alliance Commercial |
$1,178.50
|
| Rate for Payer: WEA Trust Commercial |
$1,296.35
|
| Rate for Payer: WPS Commercial |
$1,745.83
|
|
|
Multiple Lead Implantable Cardioverter-Defib 9328426
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 93284 26
|
| Hospital Charge Code |
3375523
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$54.34 |
| 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: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$338.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.34
|
| 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 |
$214.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$214.59
|
| 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: United Healthcare Medicaid |
$54.34
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
Multiple Lead Pacemaker System 9328126
|
Professional
|
Both
|
$809.00
|
|
|
Service Code
|
CPT 93281 26
|
| Hospital Charge Code |
4464703
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$58.03 |
| Max. Negotiated Rate |
$768.55 |
| Rate for Payer: Aetna Commercial |
$768.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$768.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$485.40
|
| Rate for Payer: Health EOS Commercial |
$736.19
|
| Rate for Payer: HFN Commercial |
$768.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$146.78
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: Preferred Network Access Commercial |
$768.55
|
| Rate for Payer: Quartz Beloit One Network |
$355.96
|
| Rate for Payer: Quartz Commercial |
$461.13
|
| Rate for Payer: The Alliance Commercial |
$404.50
|
| Rate for Payer: United Healthcare Medicaid |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
