|
Myelin Basic Protein Cerebrospinal Fluid
|
Facility
|
IP
|
$491.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
978023
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$240.59 |
| Max. Negotiated Rate |
$451.72 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$294.60
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$294.60
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
Myelin Basic Protein Cerebrospinal Fluid
|
Facility
|
OP
|
$491.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
978023
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$451.72 |
| Rate for Payer: Aetna Commercial |
$441.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Aetna Managed Medicare |
$17.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.55
|
| Rate for Payer: Anthem Medicaid |
$17.77
|
| Rate for Payer: Anthem Medicare Advantage |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$260.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.20
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$451.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$274.76
|
| Rate for Payer: Dean Health Medicaid |
$17.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.20
|
| Rate for Payer: Health EOS Commercial |
$436.99
|
| Rate for Payer: HFN Commercial |
$451.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.20
|
| Rate for Payer: Managed Health Services Medicaid |
$18.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.20
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.80
|
| Rate for Payer: Preferred Network Access Commercial |
$451.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.77
|
| Rate for Payer: Quartz Beloit One Network |
$240.59
|
| Rate for Payer: Quartz Commercial |
$319.15
|
| Rate for Payer: Quartz Medicare Advantage |
$17.20
|
| Rate for Payer: The Alliance Commercial |
$68.80
|
| Rate for Payer: United Healthcare Medicaid |
$17.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.20
|
| Rate for Payer: United Healthcare PPO |
$368.25
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: Wellcare Medicare |
$17.20
|
| Rate for Payer: WMAP Medicaid |
$17.77
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
Myelin Basic Protein Cerebrospinal Fluid
|
Professional
|
Both
|
$491.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
978023
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.72 |
| Max. Negotiated Rate |
$466.45 |
| Rate for Payer: Aetna Commercial |
$466.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$422.26
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cigna Commercial |
$466.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$245.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.60
|
| Rate for Payer: Health EOS Commercial |
$446.81
|
| Rate for Payer: HFN Commercial |
$466.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.72
|
| Rate for Payer: Multiplan Commercial |
$392.80
|
| Rate for Payer: Preferred Network Access Commercial |
$466.45
|
| Rate for Payer: Quartz Beloit One Network |
$216.04
|
| Rate for Payer: Quartz Commercial |
$279.87
|
| Rate for Payer: The Alliance Commercial |
$245.50
|
| Rate for Payer: WEA Trust Commercial |
$270.05
|
| Rate for Payer: WPS Commercial |
$363.68
|
|
|
Myelin Basic Protein CSF
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
1114848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$157.29 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$192.60
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$192.60
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Myelin Basic Protein CSF
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
CPT 83873
|
| Hospital Charge Code |
1114848
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$295.32 |
| Rate for Payer: Aetna Commercial |
$288.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.06
|
| Rate for Payer: Aetna Managed Medicare |
$17.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.55
|
| Rate for Payer: Anthem Medicaid |
$17.77
|
| Rate for Payer: Anthem Medicare Advantage |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.20
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$295.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.63
|
| Rate for Payer: Dean Health Medicaid |
$17.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.20
|
| Rate for Payer: Health EOS Commercial |
$285.69
|
| Rate for Payer: HFN Commercial |
$295.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.20
|
| Rate for Payer: Managed Health Services Medicaid |
$18.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.20
|
| Rate for Payer: Multiplan Commercial |
$256.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.80
|
| Rate for Payer: Preferred Network Access Commercial |
$295.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.77
|
| Rate for Payer: Quartz Beloit One Network |
$157.29
|
| Rate for Payer: Quartz Commercial |
$208.65
|
| Rate for Payer: Quartz Medicare Advantage |
$17.20
|
| Rate for Payer: The Alliance Commercial |
$68.80
|
| Rate for Payer: United Healthcare Medicaid |
$17.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.20
|
| Rate for Payer: United Healthcare PPO |
$240.75
|
| Rate for Payer: WEA Trust Commercial |
$176.55
|
| Rate for Payer: Wellcare Medicare |
$17.20
|
| Rate for Payer: WMAP Medicaid |
$17.77
|
| Rate for Payer: WPS Commercial |
$237.76
|
|
|
Myelin Oligodendrocyte Glycoprotein Antibody
|
Facility
|
IP
|
$686.40
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
5595323
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$336.34 |
| Max. Negotiated Rate |
$631.49 |
| Rate for Payer: Aetna Commercial |
$617.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.79
|
| Rate for Payer: Cash Price |
$205.92
|
| Rate for Payer: Cigna Commercial |
$631.49
|
| Rate for Payer: Health EOS Commercial |
$610.90
|
| Rate for Payer: HFN Commercial |
$631.49
|
| Rate for Payer: Multiplan Commercial |
$549.12
|
| Rate for Payer: NAPHCARE Commercial |
$411.84
|
| Rate for Payer: Preferred Network Access Commercial |
$631.49
|
| Rate for Payer: Quartz Beloit One Network |
$336.34
|
| Rate for Payer: Quartz Commercial |
$411.84
|
| Rate for Payer: WEA Trust Commercial |
$377.52
|
| Rate for Payer: WPS Commercial |
$508.42
|
|
|
Myelin Oligodendrocyte Glycoprotein Antibody
|
Professional
|
Both
|
$686.40
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
5595323
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$302.02 |
| Max. Negotiated Rate |
$652.08 |
| Rate for Payer: Aetna Commercial |
$652.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.30
|
| Rate for Payer: Cash Price |
$205.92
|
| Rate for Payer: Cigna Commercial |
$652.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$343.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$411.84
|
| Rate for Payer: Health EOS Commercial |
$624.62
|
| Rate for Payer: HFN Commercial |
$652.08
|
| Rate for Payer: Multiplan Commercial |
$549.12
|
| Rate for Payer: Preferred Network Access Commercial |
$652.08
|
| Rate for Payer: Quartz Beloit One Network |
$302.02
|
| Rate for Payer: Quartz Commercial |
$391.25
|
| Rate for Payer: The Alliance Commercial |
$343.20
|
| Rate for Payer: WEA Trust Commercial |
$377.52
|
| Rate for Payer: WPS Commercial |
$508.42
|
|
|
Myelin Oligodendrocyte Glycoprotein Antibody
|
Facility
|
OP
|
$686.40
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
5595323
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$631.49 |
| Rate for Payer: Aetna Commercial |
$617.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.30
|
| 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 |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.79
|
| 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 |
$205.92
|
| Rate for Payer: Cash Price |
$205.92
|
| Rate for Payer: Cigna Commercial |
$631.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$384.11
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$610.90
|
| Rate for Payer: HFN Commercial |
$631.49
|
| 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 |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| 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 |
$549.12
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$631.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$336.34
|
| Rate for Payer: Quartz Commercial |
$446.16
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$514.80
|
| Rate for Payer: WEA Trust Commercial |
$377.52
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$508.42
|
|
|
Myeloperoxidase Antibody
|
Professional
|
Both
|
$236.00
|
|
|
Service Code
|
CPT 86021
|
| Hospital Charge Code |
2942859
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.13 |
| Max. Negotiated Rate |
$224.20 |
| Rate for Payer: Aetna Commercial |
$224.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$224.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.60
|
| Rate for Payer: Health EOS Commercial |
$214.76
|
| Rate for Payer: HFN Commercial |
$224.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.13
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: Preferred Network Access Commercial |
$224.20
|
| Rate for Payer: Quartz Beloit One Network |
$103.84
|
| Rate for Payer: Quartz Commercial |
$134.52
|
| Rate for Payer: The Alliance Commercial |
$118.00
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
Myeloperoxidase Antibody
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
CPT 86021
|
| Hospital Charge Code |
2942859
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.64 |
| Max. Negotiated Rate |
$217.12 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$141.60
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
Myeloperoxidase Antibody
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
CPT 86021
|
| Hospital Charge Code |
2942859
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$217.12 |
| Rate for Payer: Aetna Commercial |
$212.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.96
|
| Rate for Payer: Aetna Managed Medicare |
$15.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.34
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.98
|
| Rate for Payer: Anthem Medicaid |
$15.55
|
| Rate for Payer: Anthem Medicare Advantage |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.05
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$217.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$132.07
|
| Rate for Payer: Dean Health Medicaid |
$15.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.05
|
| Rate for Payer: Health EOS Commercial |
$210.04
|
| Rate for Payer: HFN Commercial |
$217.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.05
|
| Rate for Payer: Managed Health Services Medicaid |
$16.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.05
|
| Rate for Payer: Multiplan Commercial |
$188.80
|
| Rate for Payer: NAPHCARE Commercial |
$22.58
|
| Rate for Payer: Preferred Network Access Commercial |
$217.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.55
|
| Rate for Payer: Quartz Beloit One Network |
$115.64
|
| Rate for Payer: Quartz Commercial |
$153.40
|
| Rate for Payer: Quartz Medicare Advantage |
$15.05
|
| Rate for Payer: The Alliance Commercial |
$60.20
|
| Rate for Payer: United Healthcare Medicaid |
$15.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.05
|
| Rate for Payer: United Healthcare PPO |
$177.00
|
| Rate for Payer: WEA Trust Commercial |
$129.80
|
| Rate for Payer: Wellcare Medicare |
$15.05
|
| Rate for Payer: WMAP Medicaid |
$15.55
|
| Rate for Payer: WPS Commercial |
$174.81
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC
|
Facility
|
IP
|
$61,925.00
|
|
|
Service Code
|
MSDRG 827
|
| Min. Negotiated Rate |
$22,275.34 |
| Max. Negotiated Rate |
$61,925.00 |
| Rate for Payer: Aetna Managed Medicare |
$22,275.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48,673.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$37,307.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35,444.96
|
| Rate for Payer: Anthem Medicare Advantage |
$22,275.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22,275.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22,275.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$22,275.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39,347.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$22,275.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45,185.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22,275.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22,275.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$22,275.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$22,275.34
|
| Rate for Payer: NAPHCARE Commercial |
$33,413.01
|
| Rate for Payer: Quartz Medicare Advantage |
$22,275.34
|
| Rate for Payer: The Alliance Commercial |
$61,925.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22,275.34
|
| Rate for Payer: United Healthcare PPO |
$35,177.41
|
| Rate for Payer: Wellcare Medicare |
$22,275.34
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC
|
Facility
|
IP
|
$123,352.00
|
|
|
Service Code
|
MSDRG 826
|
| Min. Negotiated Rate |
$44,371.32 |
| Max. Negotiated Rate |
$123,352.00 |
| Rate for Payer: Aetna Managed Medicare |
$44,371.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$92,102.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$70,595.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$67,070.42
|
| Rate for Payer: Anthem Medicare Advantage |
$44,371.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$44,371.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$44,371.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$44,371.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74,454.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$44,371.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85,581.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44,371.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$44,371.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$44,371.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$44,371.32
|
| Rate for Payer: NAPHCARE Commercial |
$66,556.98
|
| Rate for Payer: Quartz Medicare Advantage |
$44,371.32
|
| Rate for Payer: The Alliance Commercial |
$123,352.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$44,371.32
|
| Rate for Payer: United Healthcare PPO |
$66,626.37
|
| Rate for Payer: Wellcare Medicare |
$44,371.32
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$43,932.00
|
|
|
Service Code
|
MSDRG 828
|
| Min. Negotiated Rate |
$15,802.89 |
| Max. Negotiated Rate |
$43,932.00 |
| Rate for Payer: Aetna Managed Medicare |
$15,802.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,407.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,372.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,055.92
|
| Rate for Payer: Anthem Medicare Advantage |
$15,802.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,802.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,802.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,802.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,814.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,802.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,987.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,802.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,802.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,802.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,802.89
|
| Rate for Payer: NAPHCARE Commercial |
$23,704.34
|
| Rate for Payer: Quartz Medicare Advantage |
$15,802.89
|
| Rate for Payer: The Alliance Commercial |
$43,932.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,802.89
|
| Rate for Payer: United Healthcare PPO |
$24,902.91
|
| Rate for Payer: Wellcare Medicare |
$15,802.89
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$84,167.00
|
|
|
Service Code
|
MSDRG 829
|
| Min. Negotiated Rate |
$30,275.98 |
| Max. Negotiated Rate |
$84,167.00 |
| Rate for Payer: Aetna Managed Medicare |
$30,275.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66,087.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50,655.15
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48,125.70
|
| Rate for Payer: Anthem Medicare Advantage |
$30,275.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30,275.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30,275.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30,275.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53,423.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30,275.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61,499.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30,275.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30,275.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30,275.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30,275.98
|
| Rate for Payer: NAPHCARE Commercial |
$45,413.97
|
| Rate for Payer: Quartz Medicare Advantage |
$30,275.98
|
| Rate for Payer: The Alliance Commercial |
$84,167.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30,275.98
|
| Rate for Payer: United Healthcare PPO |
$47,877.84
|
| Rate for Payer: Wellcare Medicare |
$30,275.98
|
|
|
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$42,358.00
|
|
|
Service Code
|
MSDRG 830
|
| Min. Negotiated Rate |
$15,236.75 |
| Max. Negotiated Rate |
$42,358.00 |
| Rate for Payer: Wellcare Medicare |
$15,236.75
|
| Rate for Payer: Aetna Managed Medicare |
$15,236.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,148.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,407.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,139.24
|
| Rate for Payer: Anthem Medicare Advantage |
$15,236.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,236.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,236.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,236.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26,796.77
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,236.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,833.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,236.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,236.75
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,236.75
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,236.75
|
| Rate for Payer: NAPHCARE Commercial |
$22,855.12
|
| Rate for Payer: Quartz Medicare Advantage |
$15,236.75
|
| Rate for Payer: The Alliance Commercial |
$42,358.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,236.75
|
| Rate for Payer: United Healthcare PPO |
$24,004.20
|
|
|
MYH Gene Analysis
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4602759
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.64 |
| Max. Negotiated Rate |
$483.61 |
| 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 |
$483.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$483.61
|
| 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
|
|
|
MYH Gene Analysis
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4602759
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.00 |
| Max. Negotiated Rate |
$548.00 |
| Rate for Payer: Aetna Commercial |
$320.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$306.16
|
| Rate for Payer: Aetna Managed Medicare |
$137.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$513.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$239.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$227.42
|
| Rate for Payer: Anthem Medicaid |
$137.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.00
|
| 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 |
$137.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.00
|
| 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 |
$137.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$137.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$199.22
|
| Rate for Payer: Dean Health Medicaid |
$137.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.00
|
| Rate for Payer: Health EOS Commercial |
$316.84
|
| Rate for Payer: HFN Commercial |
$327.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$509.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$137.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.00
|
| Rate for Payer: Managed Health Services Medicaid |
$142.48
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.00
|
| Rate for Payer: Multiplan Commercial |
$284.80
|
| Rate for Payer: NAPHCARE Commercial |
$205.50
|
| Rate for Payer: Preferred Network Access Commercial |
$327.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$137.00
|
| Rate for Payer: Quartz Beloit One Network |
$174.44
|
| Rate for Payer: Quartz Commercial |
$231.40
|
| Rate for Payer: Quartz Medicare Advantage |
$137.00
|
| Rate for Payer: The Alliance Commercial |
$548.00
|
| Rate for Payer: United Healthcare Medicaid |
$137.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.00
|
| Rate for Payer: United Healthcare PPO |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$195.80
|
| Rate for Payer: Wellcare Medicare |
$137.00
|
| Rate for Payer: WMAP Medicaid |
$137.00
|
| Rate for Payer: WPS Commercial |
$263.69
|
|
|
MYH Gene Analysis
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 81401
|
| Hospital Charge Code |
4602759
|
|
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
|
|
|
MYLICON WHITE W/BLCK LTR #ANW
|
Facility
|
OP
|
$202.00
|
|
| Hospital Charge Code |
2974885
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$56.56 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna Commercial |
$181.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.72
|
| Rate for Payer: Aetna Managed Medicare |
$56.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$101.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$107.06
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$185.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$113.04
|
| Rate for Payer: Health EOS Commercial |
$179.78
|
| Rate for Payer: HFN Commercial |
$185.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$151.50
|
| Rate for Payer: Multiplan Commercial |
$161.60
|
| Rate for Payer: NAPHCARE Commercial |
$121.20
|
| Rate for Payer: Preferred Network Access Commercial |
$185.84
|
| Rate for Payer: Quartz Beloit One Network |
$98.98
|
| Rate for Payer: Quartz Commercial |
$131.30
|
| Rate for Payer: Quartz Medicare Advantage |
$121.20
|
| Rate for Payer: The Alliance Commercial |
$808.00
|
| Rate for Payer: WEA Trust Commercial |
$111.10
|
| Rate for Payer: WPS Commercial |
$149.62
|
|
|
MYLICON WHITE W/BLCK LTR #ANW
|
Facility
|
IP
|
$202.00
|
|
| Hospital Charge Code |
2974885
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$98.98 |
| Max. Negotiated Rate |
$185.84 |
| Rate for Payer: Aetna Commercial |
$181.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$173.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$107.06
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$185.84
|
| Rate for Payer: Health EOS Commercial |
$179.78
|
| Rate for Payer: HFN Commercial |
$185.84
|
| Rate for Payer: Multiplan Commercial |
$161.60
|
| Rate for Payer: NAPHCARE Commercial |
$121.20
|
| Rate for Payer: Preferred Network Access Commercial |
$185.84
|
| Rate for Payer: Quartz Beloit One Network |
$98.98
|
| Rate for Payer: Quartz Commercial |
$121.20
|
| Rate for Payer: WEA Trust Commercial |
$111.10
|
| Rate for Payer: WPS Commercial |
$149.62
|
|
|
Myocardial Perfusion Planar Multiple Studies 7845426
|
Professional
|
Both
|
$1,193.00
|
|
|
Service Code
|
CPT 78454 26
|
| Hospital Charge Code |
4494936
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$221.40 |
| Max. Negotiated Rate |
$1,133.35 |
| Rate for Payer: Aetna Commercial |
$1,133.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,025.98
|
| Rate for Payer: Cash Price |
$357.90
|
| Rate for Payer: Cash Price |
$357.90
|
| Rate for Payer: Cash Price |
$357.90
|
| Rate for Payer: Cigna Commercial |
$1,133.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$596.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$715.80
|
| Rate for Payer: Health EOS Commercial |
$1,085.63
|
| Rate for Payer: HFN Commercial |
$1,133.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$221.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$221.40
|
| Rate for Payer: Multiplan Commercial |
$954.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,133.35
|
| Rate for Payer: Quartz Beloit One Network |
$524.92
|
| Rate for Payer: Quartz Commercial |
$680.01
|
| Rate for Payer: The Alliance Commercial |
$596.50
|
| Rate for Payer: WEA Trust Commercial |
$656.15
|
| Rate for Payer: WPS Commercial |
$883.66
|
|
|
MYOCUTANEOUS ADV FLAP FOR VENTRAL HERNIA
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960118
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
MYOCUTANEOUS ADV FLAP FOR VENTRAL HERNIA
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960118
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
Myoglobin
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
CPT 83874
|
| Hospital Charge Code |
633786
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.61 |
| Max. Negotiated Rate |
$250.80 |
| Rate for Payer: Aetna Commercial |
$250.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$227.04
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$250.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$132.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.40
|
| Rate for Payer: Health EOS Commercial |
$240.24
|
| Rate for Payer: HFN Commercial |
$250.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.61
|
| Rate for Payer: Multiplan Commercial |
$211.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.80
|
| Rate for Payer: Quartz Beloit One Network |
$116.16
|
| Rate for Payer: Quartz Commercial |
$150.48
|
| Rate for Payer: The Alliance Commercial |
$132.00
|
| Rate for Payer: WEA Trust Commercial |
$145.20
|
| Rate for Payer: WPS Commercial |
$195.54
|
|
