|
Normal saline solution infus J7030
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
3600901
|
|
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
|
|
|
Norm Saline PB 1000Cc
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3040289
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Norm Saline PB 1000Cc
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040289
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Norovirus Gll
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$144.75
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Norovirus Gll
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.92 |
| Max. Negotiated Rate |
$183.35 |
| Rate for Payer: Aetna Commercial |
$183.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$183.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.80
|
| Rate for Payer: Health EOS Commercial |
$175.63
|
| Rate for Payer: HFN Commercial |
$183.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.35
|
| Rate for Payer: Quartz Beloit One Network |
$84.92
|
| Rate for Payer: Quartz Commercial |
$110.01
|
| Rate for Payer: The Alliance Commercial |
$96.50
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Norovirus Gll
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
Norovirus PCR to Quest
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$123.87 |
| Max. Negotiated Rate |
$348.65 |
| Rate for Payer: Aetna Commercial |
$348.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$348.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$183.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.20
|
| Rate for Payer: Health EOS Commercial |
$333.97
|
| Rate for Payer: HFN Commercial |
$348.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: Preferred Network Access Commercial |
$348.65
|
| Rate for Payer: Quartz Beloit One Network |
$161.48
|
| Rate for Payer: Quartz Commercial |
$209.19
|
| Rate for Payer: The Alliance Commercial |
$183.50
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
Norovirus PCR to Quest
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$205.37
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$238.55
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$275.25
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
Norovirus PCR to Quest
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$179.83 |
| Max. Negotiated Rate |
$337.64 |
| Rate for Payer: Aetna Commercial |
$330.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$315.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$194.51
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$337.64
|
| Rate for Payer: Health EOS Commercial |
$326.63
|
| Rate for Payer: HFN Commercial |
$337.64
|
| Rate for Payer: Multiplan Commercial |
$293.60
|
| Rate for Payer: NAPHCARE Commercial |
$220.20
|
| Rate for Payer: Preferred Network Access Commercial |
$337.64
|
| Rate for Payer: Quartz Beloit One Network |
$179.83
|
| Rate for Payer: Quartz Commercial |
$220.20
|
| Rate for Payer: WEA Trust Commercial |
$201.85
|
| Rate for Payer: WPS Commercial |
$271.84
|
|
|
Nortriptyline Level
|
Facility
|
OP
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.44 |
| Max. Negotiated Rate |
$1,992.00 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Aetna Managed Medicare |
$139.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$323.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$278.68
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$373.50
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$323.70
|
| Rate for Payer: Quartz Medicare Advantage |
$298.80
|
| Rate for Payer: The Alliance Commercial |
$1,992.00
|
| Rate for Payer: United Healthcare PPO |
$373.50
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
Nortriptyline Level
|
Professional
|
Both
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$473.10 |
| Rate for Payer: Aetna Commercial |
$473.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$473.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$249.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.80
|
| Rate for Payer: Health EOS Commercial |
$453.18
|
| Rate for Payer: HFN Commercial |
$473.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: Preferred Network Access Commercial |
$473.10
|
| Rate for Payer: Quartz Beloit One Network |
$219.12
|
| Rate for Payer: Quartz Commercial |
$283.86
|
| Rate for Payer: The Alliance Commercial |
$249.00
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
Nortriptyline Level
|
Facility
|
IP
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$244.02 |
| Max. Negotiated Rate |
$458.16 |
| Rate for Payer: Aetna Commercial |
$448.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$428.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$263.94
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$458.16
|
| Rate for Payer: Health EOS Commercial |
$443.22
|
| Rate for Payer: HFN Commercial |
$458.16
|
| Rate for Payer: Multiplan Commercial |
$398.40
|
| Rate for Payer: NAPHCARE Commercial |
$298.80
|
| Rate for Payer: Preferred Network Access Commercial |
$458.16
|
| Rate for Payer: Quartz Beloit One Network |
$244.02
|
| Rate for Payer: Quartz Commercial |
$298.80
|
| Rate for Payer: WEA Trust Commercial |
$273.90
|
| Rate for Payer: WPS Commercial |
$368.87
|
|
|
NOSEBLEED WOUND SEAL MD NPS861
|
Facility
|
IP
|
$130.00
|
|
| Hospital Charge Code |
3000484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$119.60 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$78.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
NOSEBLEED WOUND SEAL MD NPS861
|
Facility
|
OP
|
$130.00
|
|
| Hospital Charge Code |
3000484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Aetna Commercial |
$117.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$111.80
|
| Rate for Payer: Aetna Managed Medicare |
$36.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$84.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$65.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$62.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.90
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$119.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.75
|
| Rate for Payer: Health EOS Commercial |
$115.70
|
| Rate for Payer: HFN Commercial |
$119.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$97.50
|
| Rate for Payer: Multiplan Commercial |
$104.00
|
| Rate for Payer: NAPHCARE Commercial |
$78.00
|
| Rate for Payer: Preferred Network Access Commercial |
$119.60
|
| Rate for Payer: Quartz Beloit One Network |
$63.70
|
| Rate for Payer: Quartz Commercial |
$84.50
|
| Rate for Payer: Quartz Medicare Advantage |
$78.00
|
| Rate for Payer: The Alliance Commercial |
$520.00
|
| Rate for Payer: WEA Trust Commercial |
$71.50
|
| Rate for Payer: WPS Commercial |
$96.29
|
|
|
NOVASURE ABLATION KIT NSV5KITUS-001
|
Facility
|
OP
|
$10,193.00
|
|
|
Service Code
|
HCPCS A4404
|
| Hospital Charge Code |
2962808
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,854.04 |
| Max. Negotiated Rate |
$40,772.00 |
| Rate for Payer: Aetna Commercial |
$9,173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,765.98
|
| Rate for Payer: Aetna Managed Medicare |
$2,854.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,625.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,096.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,892.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,402.29
|
| Rate for Payer: Cash Price |
$3,057.90
|
| Rate for Payer: Cigna Commercial |
$9,377.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,704.00
|
| Rate for Payer: Health EOS Commercial |
$9,071.77
|
| Rate for Payer: HFN Commercial |
$9,377.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,644.75
|
| Rate for Payer: Multiplan Commercial |
$8,154.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,377.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,994.57
|
| Rate for Payer: Quartz Commercial |
$6,625.45
|
| Rate for Payer: Quartz Medicare Advantage |
$6,115.80
|
| Rate for Payer: The Alliance Commercial |
$40,772.00
|
| Rate for Payer: WEA Trust Commercial |
$5,606.15
|
| Rate for Payer: WPS Commercial |
$7,549.96
|
|
|
NOVASURE ABLATION KIT NSV5KITUS-001
|
Facility
|
IP
|
$10,193.00
|
|
|
Service Code
|
HCPCS A4404
|
| Hospital Charge Code |
2962808
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,994.57 |
| Max. Negotiated Rate |
$9,377.56 |
| Rate for Payer: Aetna Commercial |
$9,173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,765.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,402.29
|
| Rate for Payer: Cash Price |
$3,057.90
|
| Rate for Payer: Cigna Commercial |
$9,377.56
|
| Rate for Payer: Health EOS Commercial |
$9,071.77
|
| Rate for Payer: HFN Commercial |
$9,377.56
|
| Rate for Payer: Multiplan Commercial |
$8,154.40
|
| Rate for Payer: NAPHCARE Commercial |
$6,115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,377.56
|
| Rate for Payer: Quartz Beloit One Network |
$4,994.57
|
| Rate for Payer: Quartz Commercial |
$6,115.80
|
| Rate for Payer: WEA Trust Commercial |
$5,606.15
|
| Rate for Payer: WPS Commercial |
$7,549.96
|
|
|
NOZZLE FEMORAL BREAKAWAY 0606-512-000
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
2963181
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
NOZZLE FEMORAL BREAKAWAY 0606-512-000
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
2963181
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
NST - Devices and Equipment
|
Facility
|
IP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3052330
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
NST - Devices and Equipment
|
Facility
|
OP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3052330
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$196.96 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$196.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$559.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$413.28
|
| Rate for Payer: Anthem Medicare Advantage |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$196.96
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$196.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$196.96
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$732.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$196.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$196.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$196.96
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$295.44
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$559.65
|
| Rate for Payer: Quartz Medicare Advantage |
$196.96
|
| Rate for Payer: The Alliance Commercial |
$787.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$196.96
|
| Rate for Payer: United Healthcare PPO |
$645.75
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: Wellcare Medicare |
$196.96
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
NST - Individual Charges
|
Facility
|
OP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3040449
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$196.96 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Aetna Managed Medicare |
$196.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$559.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$430.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$413.28
|
| Rate for Payer: Anthem Medicare Advantage |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$196.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$196.96
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$196.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$196.96
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$732.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$196.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$196.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$196.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$196.96
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$295.44
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$559.65
|
| Rate for Payer: Quartz Medicare Advantage |
$196.96
|
| Rate for Payer: The Alliance Commercial |
$787.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$196.96
|
| Rate for Payer: United Healthcare PPO |
$645.75
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: Wellcare Medicare |
$196.96
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
NST - Individual Charges
|
Facility
|
IP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3040449
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$421.89 |
| Max. Negotiated Rate |
$792.12 |
| Rate for Payer: Aetna Commercial |
$774.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$740.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$456.33
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$792.12
|
| Rate for Payer: Health EOS Commercial |
$766.29
|
| Rate for Payer: HFN Commercial |
$792.12
|
| Rate for Payer: Multiplan Commercial |
$688.80
|
| Rate for Payer: NAPHCARE Commercial |
$516.60
|
| Rate for Payer: Preferred Network Access Commercial |
$792.12
|
| Rate for Payer: Quartz Beloit One Network |
$421.89
|
| Rate for Payer: Quartz Commercial |
$516.60
|
| Rate for Payer: WEA Trust Commercial |
$473.55
|
| Rate for Payer: WPS Commercial |
$637.74
|
|
|
N-Telopeptide Cross Links Urine
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
978025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.94 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna Commercial |
$228.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$228.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.00
|
| Rate for Payer: Health EOS Commercial |
$218.40
|
| Rate for Payer: HFN Commercial |
$228.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.94
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$228.00
|
| Rate for Payer: Quartz Beloit One Network |
$105.60
|
| Rate for Payer: Quartz Commercial |
$136.80
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
N-Telopeptide Cross Links Urine
|
Facility
|
OP
|
$240.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
978025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Aetna Managed Medicare |
$18.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.01
|
| Rate for Payer: Anthem Medicaid |
$14.65
|
| Rate for Payer: Anthem Medicare Advantage |
$18.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.68
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.30
|
| Rate for Payer: Dean Health Medicaid |
$14.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.68
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.68
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.68
|
| Rate for Payer: Managed Health Services Medicaid |
$15.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.68
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.68
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$28.02
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.65
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$156.00
|
| Rate for Payer: Quartz Medicare Advantage |
$18.68
|
| Rate for Payer: The Alliance Commercial |
$74.72
|
| Rate for Payer: United Healthcare Medicaid |
$14.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.68
|
| Rate for Payer: United Healthcare PPO |
$180.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: Wellcare Medicare |
$18.68
|
| Rate for Payer: WMAP Medicaid |
$14.65
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
|
N-Telopeptide Cross Links Urine
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
978025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$220.80 |
| Rate for Payer: Aetna Commercial |
$216.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$206.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.20
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$220.80
|
| Rate for Payer: Health EOS Commercial |
$213.60
|
| Rate for Payer: HFN Commercial |
$220.80
|
| Rate for Payer: Multiplan Commercial |
$192.00
|
| Rate for Payer: NAPHCARE Commercial |
$144.00
|
| Rate for Payer: Preferred Network Access Commercial |
$220.80
|
| Rate for Payer: Quartz Beloit One Network |
$117.60
|
| Rate for Payer: Quartz Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$132.00
|
| Rate for Payer: WPS Commercial |
$177.77
|
|
