|
Oligoclonal Bands CSF
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
CPT 83916
|
| Hospital Charge Code |
2958995
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$191.59 |
| Max. Negotiated Rate |
$359.72 |
| Rate for Payer: Aetna Commercial |
$351.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$336.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$207.23
|
| Rate for Payer: Cash Price |
$117.30
|
| Rate for Payer: Cigna Commercial |
$359.72
|
| Rate for Payer: Health EOS Commercial |
$347.99
|
| Rate for Payer: HFN Commercial |
$359.72
|
| Rate for Payer: Multiplan Commercial |
$312.80
|
| Rate for Payer: NAPHCARE Commercial |
$234.60
|
| Rate for Payer: Preferred Network Access Commercial |
$359.72
|
| Rate for Payer: Quartz Beloit One Network |
$191.59
|
| Rate for Payer: Quartz Commercial |
$234.60
|
| Rate for Payer: WEA Trust Commercial |
$215.05
|
| Rate for Payer: WPS Commercial |
$289.61
|
|
|
Oligosaccharide Screen, Urine
|
Facility
|
IP
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$311.88 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.67
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$311.88
|
| Rate for Payer: Health EOS Commercial |
$301.71
|
| Rate for Payer: HFN Commercial |
$311.88
|
| Rate for Payer: Multiplan Commercial |
$271.20
|
| Rate for Payer: NAPHCARE Commercial |
$203.40
|
| Rate for Payer: Preferred Network Access Commercial |
$311.88
|
| Rate for Payer: Quartz Beloit One Network |
$166.11
|
| Rate for Payer: Quartz Commercial |
$203.40
|
| Rate for Payer: WEA Trust Commercial |
$186.45
|
| Rate for Payer: WPS Commercial |
$251.10
|
|
|
Oligosaccharide Screen, Urine
|
Facility
|
OP
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$311.88 |
| Rate for Payer: Aetna Commercial |
$305.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.54
|
| Rate for Payer: Aetna Managed Medicare |
$5.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.13
|
| Rate for Payer: Anthem Medicaid |
$5.68
|
| Rate for Payer: Anthem Medicare Advantage |
$5.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$179.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.50
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$311.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$189.70
|
| Rate for Payer: Dean Health Medicaid |
$5.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.50
|
| Rate for Payer: Health EOS Commercial |
$301.71
|
| Rate for Payer: HFN Commercial |
$311.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.50
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.50
|
| Rate for Payer: Managed Health Services Medicaid |
$5.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$271.20
|
| Rate for Payer: NAPHCARE Commercial |
$8.25
|
| Rate for Payer: Preferred Network Access Commercial |
$311.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.68
|
| Rate for Payer: Quartz Beloit One Network |
$166.11
|
| Rate for Payer: Quartz Commercial |
$220.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5.50
|
| Rate for Payer: The Alliance Commercial |
$22.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.50
|
| Rate for Payer: United Healthcare PPO |
$254.25
|
| Rate for Payer: WEA Trust Commercial |
$186.45
|
| Rate for Payer: Wellcare Medicare |
$5.50
|
| Rate for Payer: WMAP Medicaid |
$5.68
|
| Rate for Payer: WPS Commercial |
$251.10
|
|
|
Oligosaccharide Screen, Urine
|
Professional
|
Both
|
$339.00
|
|
|
Service Code
|
CPT 84376
|
| Hospital Charge Code |
1124803
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.42 |
| Max. Negotiated Rate |
$322.05 |
| Rate for Payer: Aetna Commercial |
$322.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$291.54
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cash Price |
$101.70
|
| Rate for Payer: Cigna Commercial |
$322.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$169.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.40
|
| Rate for Payer: Health EOS Commercial |
$308.49
|
| Rate for Payer: HFN Commercial |
$322.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.42
|
| Rate for Payer: Multiplan Commercial |
$271.20
|
| Rate for Payer: Preferred Network Access Commercial |
$322.05
|
| Rate for Payer: Quartz Beloit One Network |
$149.16
|
| Rate for Payer: Quartz Commercial |
$193.23
|
| Rate for Payer: The Alliance Commercial |
$169.50
|
| Rate for Payer: WEA Trust Commercial |
$186.45
|
| Rate for Payer: WPS Commercial |
$251.10
|
|
|
OLYMPUS 3MM ROLLER BALL 24FR M0068802641
|
Facility
|
OP
|
$1,134.00
|
|
| Hospital Charge Code |
4520042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$317.52 |
| Max. Negotiated Rate |
$4,536.00 |
| Rate for Payer: Aetna Commercial |
$1,020.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$975.24
|
| Rate for Payer: Aetna Managed Medicare |
$317.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$737.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$567.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$544.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.02
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Cigna Commercial |
$1,043.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$634.59
|
| Rate for Payer: Health EOS Commercial |
$1,009.26
|
| Rate for Payer: HFN Commercial |
$1,043.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$850.50
|
| Rate for Payer: Multiplan Commercial |
$907.20
|
| Rate for Payer: NAPHCARE Commercial |
$680.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,043.28
|
| Rate for Payer: Quartz Beloit One Network |
$555.66
|
| Rate for Payer: Quartz Commercial |
$737.10
|
| Rate for Payer: Quartz Medicare Advantage |
$680.40
|
| Rate for Payer: The Alliance Commercial |
$4,536.00
|
| Rate for Payer: WEA Trust Commercial |
$623.70
|
| Rate for Payer: WPS Commercial |
$839.95
|
|
|
OLYMPUS 3MM ROLLER BALL 24FR M0068802641
|
Facility
|
IP
|
$1,134.00
|
|
| Hospital Charge Code |
4520042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$555.66 |
| Max. Negotiated Rate |
$1,043.28 |
| Rate for Payer: Aetna Commercial |
$1,020.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$975.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$601.02
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Cigna Commercial |
$1,043.28
|
| Rate for Payer: Health EOS Commercial |
$1,009.26
|
| Rate for Payer: HFN Commercial |
$1,043.28
|
| Rate for Payer: Multiplan Commercial |
$907.20
|
| Rate for Payer: NAPHCARE Commercial |
$680.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,043.28
|
| Rate for Payer: Quartz Beloit One Network |
$555.66
|
| Rate for Payer: Quartz Commercial |
$680.40
|
| Rate for Payer: WEA Trust Commercial |
$623.70
|
| Rate for Payer: WPS Commercial |
$839.95
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
IP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,192.66 |
| Max. Negotiated Rate |
$2,239.28 |
| Rate for Payer: Aetna Commercial |
$2,190.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,093.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,290.02
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,239.28
|
| Rate for Payer: Health EOS Commercial |
$2,166.26
|
| Rate for Payer: HFN Commercial |
$2,239.28
|
| Rate for Payer: Multiplan Commercial |
$1,947.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,460.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,239.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,192.66
|
| Rate for Payer: Quartz Commercial |
$1,460.40
|
| Rate for Payer: WEA Trust Commercial |
$1,338.70
|
| Rate for Payer: WPS Commercial |
$1,802.86
|
|
|
Omalizumab Charge 150 mg/5ml
|
Professional
|
Both
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.81 |
| Max. Negotiated Rate |
$2,312.30 |
| Rate for Payer: Aetna Commercial |
$2,312.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,093.24
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,312.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.81
|
| Rate for Payer: Health EOS Commercial |
$2,214.94
|
| Rate for Payer: HFN Commercial |
$2,312.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.27
|
| Rate for Payer: Multiplan Commercial |
$1,947.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,312.30
|
| Rate for Payer: Quartz Beloit One Network |
$1,070.96
|
| Rate for Payer: Quartz Commercial |
$1,387.38
|
| Rate for Payer: The Alliance Commercial |
$1,217.00
|
| Rate for Payer: United Healthcare Medicaid |
$36.81
|
| Rate for Payer: WEA Trust Commercial |
$1,338.70
|
| Rate for Payer: WPS Commercial |
$92.02
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
OP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.46 |
| Max. Negotiated Rate |
$2,239.28 |
| Rate for Payer: Aetna Commercial |
$2,190.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,093.24
|
| Rate for Payer: Aetna Managed Medicare |
$39.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,582.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,217.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,168.32
|
| Rate for Payer: Anthem Medicare Advantage |
$39.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,290.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.46
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,239.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.46
|
| Rate for Payer: Health EOS Commercial |
$2,166.26
|
| Rate for Payer: HFN Commercial |
$2,239.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.46
|
| Rate for Payer: Multiplan Commercial |
$1,947.20
|
| Rate for Payer: NAPHCARE Commercial |
$59.19
|
| Rate for Payer: Preferred Network Access Commercial |
$2,239.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,192.66
|
| Rate for Payer: Quartz Commercial |
$1,582.10
|
| Rate for Payer: Quartz Medicare Advantage |
$39.46
|
| Rate for Payer: The Alliance Commercial |
$157.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: WEA Trust Commercial |
$1,338.70
|
| Rate for Payer: Wellcare Medicare |
$39.46
|
| Rate for Payer: WPS Commercial |
$92.02
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.88 |
| Max. Negotiated Rate |
$157.84 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$39.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.88
|
| Rate for Payer: Anthem Medicare Advantage |
$39.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.46
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.46
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.46
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$59.19
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$39.46
|
| Rate for Payer: The Alliance Commercial |
$157.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.46
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$39.46
|
| Rate for Payer: WPS Commercial |
$92.02
|
|
|
Omalizumab injection 5 Mg J2357
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.64 |
| Max. Negotiated Rate |
$92.02 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.81
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.27
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: United Healthcare Medicaid |
$36.81
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$92.02
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
OmegaCheck
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$24.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$24.89
|
| Rate for Payer: Anthem Medicare Advantage |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.09
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Dean Health Medicaid |
$24.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24.09
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.09
|
| Rate for Payer: Managed Health Services Medicaid |
$25.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24.09
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$36.14
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.89
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$24.09
|
| Rate for Payer: The Alliance Commercial |
$96.36
|
| Rate for Payer: United Healthcare Medicaid |
$24.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.09
|
| Rate for Payer: United Healthcare PPO |
$103.50
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: Wellcare Medicare |
$24.09
|
| Rate for Payer: WMAP Medicaid |
$24.89
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
OmegaCheck
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.72 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.04
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
OmegaCheck
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Omnipaque 100cc
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$142.80
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
Omnipaque 100cc
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$972.00 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Aetna Managed Medicare |
$68.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$157.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$121.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$182.25
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$157.95
|
| Rate for Payer: Quartz Medicare Advantage |
$145.80
|
| Rate for Payer: The Alliance Commercial |
$972.00
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 100cc
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$230.85 |
| Rate for Payer: Aetna Commercial |
$230.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$230.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$221.13
|
| Rate for Payer: HFN Commercial |
$230.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: Preferred Network Access Commercial |
$230.85
|
| Rate for Payer: Quartz Beloit One Network |
$106.92
|
| Rate for Payer: Quartz Commercial |
$138.51
|
| Rate for Payer: The Alliance Commercial |
$121.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 100cc
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.07 |
| Max. Negotiated Rate |
$223.56 |
| Rate for Payer: Aetna Commercial |
$218.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.79
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$223.56
|
| Rate for Payer: Health EOS Commercial |
$216.27
|
| Rate for Payer: HFN Commercial |
$223.56
|
| Rate for Payer: Multiplan Commercial |
$194.40
|
| Rate for Payer: NAPHCARE Commercial |
$145.80
|
| Rate for Payer: Preferred Network Access Commercial |
$223.56
|
| Rate for Payer: Quartz Beloit One Network |
$119.07
|
| Rate for Payer: Quartz Commercial |
$145.80
|
| Rate for Payer: WEA Trust Commercial |
$133.65
|
| Rate for Payer: WPS Commercial |
$179.99
|
|
|
Omnipaque 100cc
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$952.00 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$66.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$119.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$114.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$178.50
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$154.70
|
| Rate for Payer: Quartz Medicare Advantage |
$142.80
|
| Rate for Payer: The Alliance Commercial |
$952.00
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 150cc
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: The Alliance Commercial |
$182.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 150cc
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$1,456.00 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$101.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$236.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$182.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$273.00
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$218.40
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$236.60
|
| Rate for Payer: Quartz Medicare Advantage |
$218.40
|
| Rate for Payer: The Alliance Commercial |
$1,456.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 150cc
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$175.42 |
| Max. Negotiated Rate |
$329.36 |
| Rate for Payer: Aetna Commercial |
$322.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.74
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$329.36
|
| Rate for Payer: Health EOS Commercial |
$318.62
|
| Rate for Payer: HFN Commercial |
$329.36
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: NAPHCARE Commercial |
$214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$329.36
|
| Rate for Payer: Quartz Beloit One Network |
$175.42
|
| Rate for Payer: Quartz Commercial |
$214.80
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Omnipaque 150cc
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$218.40
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$218.40
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Omnipaque 150cc
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$1,432.00 |
| Rate for Payer: Aetna Commercial |
$322.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Aetna Managed Medicare |
$100.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$179.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.74
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$329.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$318.62
|
| Rate for Payer: HFN Commercial |
$329.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.50
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: NAPHCARE Commercial |
$214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$329.36
|
| Rate for Payer: Quartz Beloit One Network |
$175.42
|
| Rate for Payer: Quartz Commercial |
$232.70
|
| Rate for Payer: Quartz Medicare Advantage |
$214.80
|
| Rate for Payer: The Alliance Commercial |
$1,432.00
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
