|
Normal saline solution infus J7030
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
3600901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.07 |
| Max. Negotiated Rate |
$6.78 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$2.07
|
| Rate for Payer: Anthem Medicare Advantage |
$2.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.07
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.71
|
| Rate for Payer: Health EOS Commercial |
$4.73
|
| Rate for Payer: HFN Commercial |
$4.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.23
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.07
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.10
|
| Rate for Payer: Preferred Network Access Commercial |
$4.94
|
| Rate for Payer: Quartz Beloit One Network |
$2.29
|
| Rate for Payer: Quartz Commercial |
$2.96
|
| Rate for Payer: Quartz Medicare Advantage |
$2.07
|
| Rate for Payer: The Alliance Commercial |
$5.69
|
| Rate for Payer: United Healthcare Medicaid |
$2.07
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.07
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$6.78
|
|
|
Normal saline solution infus J7030
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J7030
|
| Hospital Charge Code |
3600901
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Norm Saline PB 1000Cc
|
Facility
|
IP
|
$2.00
|
|
| Hospital Charge Code |
3040289
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.25
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Norm Saline PB 1000Cc
|
Facility
|
OP
|
$2.00
|
|
| Hospital Charge Code |
3040289
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.16
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$1.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.25
|
| Rate for Payer: The Alliance Commercial |
$1.04
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Norovirus Gll
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Norovirus Gll
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.58
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$36.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$36.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: United Healthcare PPO |
$150.54
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: Wellcare Medicare |
$36.49
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Norovirus Gll
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
4588652
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$190.68 |
| Rate for Payer: Aetna Commercial |
$190.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$190.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$182.66
|
| Rate for Payer: HFN Commercial |
$190.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$190.68
|
| Rate for Payer: Quartz Beloit One Network |
$88.32
|
| Rate for Payer: Quartz Commercial |
$114.41
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$144.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$160.57
|
|
|
Norovirus PCR to Quest
|
Facility
|
OP
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.86
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.58
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$36.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$213.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$36.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$36.49
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$248.09
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: United Healthcare PPO |
$286.26
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: Wellcare Medicare |
$36.49
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Norovirus PCR to Quest
|
Professional
|
Both
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.49 |
| Max. Negotiated Rate |
$362.60 |
| Rate for Payer: Aetna Commercial |
$362.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$362.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$190.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$347.33
|
| Rate for Payer: HFN Commercial |
$362.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$128.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$128.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$362.60
|
| Rate for Payer: Quartz Beloit One Network |
$167.94
|
| Rate for Payer: Quartz Commercial |
$217.56
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$144.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$160.57
|
|
|
Norovirus PCR to Quest
|
Facility
|
IP
|
$367.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
5472908
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$187.02 |
| Max. Negotiated Rate |
$351.15 |
| Rate for Payer: Aetna Commercial |
$343.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$328.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$202.29
|
| Rate for Payer: Cash Price |
$110.10
|
| Rate for Payer: Cigna Commercial |
$351.15
|
| Rate for Payer: Health EOS Commercial |
$339.70
|
| Rate for Payer: HFN Commercial |
$351.15
|
| Rate for Payer: Multiplan Commercial |
$305.34
|
| Rate for Payer: Preferred Network Access Commercial |
$351.15
|
| Rate for Payer: Quartz Beloit One Network |
$187.02
|
| Rate for Payer: Quartz Commercial |
$229.01
|
| Rate for Payer: WEA Trust Commercial |
$209.92
|
| Rate for Payer: WPS Commercial |
$282.70
|
|
|
Nortriptyline Level
|
Facility
|
IP
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$253.78 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$310.75
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
Nortriptyline Level
|
Professional
|
Both
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$492.02 |
| Rate for Payer: Aetna Commercial |
$492.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$492.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$258.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$310.75
|
| Rate for Payer: Health EOS Commercial |
$471.31
|
| Rate for Payer: HFN Commercial |
$492.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: Preferred Network Access Commercial |
$492.02
|
| Rate for Payer: Quartz Beloit One Network |
$227.88
|
| Rate for Payer: Quartz Commercial |
$295.21
|
| Rate for Payer: The Alliance Commercial |
$258.96
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
Nortriptyline Level
|
Facility
|
OP
|
$498.00
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
978027
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.02 |
| Max. Negotiated Rate |
$476.49 |
| Rate for Payer: Aetna Commercial |
$466.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$445.41
|
| Rate for Payer: Aetna Managed Medicare |
$145.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$336.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$258.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$248.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$274.50
|
| Rate for Payer: Cash Price |
$149.40
|
| Rate for Payer: Cigna Commercial |
$476.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.84
|
| Rate for Payer: Health EOS Commercial |
$460.95
|
| Rate for Payer: HFN Commercial |
$476.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$388.44
|
| Rate for Payer: Multiplan Commercial |
$414.34
|
| Rate for Payer: NAPHCARE Commercial |
$310.75
|
| Rate for Payer: Preferred Network Access Commercial |
$476.49
|
| Rate for Payer: Quartz Beloit One Network |
$253.78
|
| Rate for Payer: Quartz Commercial |
$336.65
|
| Rate for Payer: Quartz Medicare Advantage |
$310.75
|
| Rate for Payer: The Alliance Commercial |
$258.96
|
| Rate for Payer: United Healthcare PPO |
$388.44
|
| Rate for Payer: WEA Trust Commercial |
$284.86
|
| Rate for Payer: WPS Commercial |
$383.61
|
|
|
NOSEBLEED WOUND SEAL MD NPS861
|
Facility
|
IP
|
$130.00
|
|
| Hospital Charge Code |
3000484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.25 |
| Max. Negotiated Rate |
$124.38 |
| Rate for Payer: Aetna Commercial |
$121.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.66
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$124.38
|
| Rate for Payer: Health EOS Commercial |
$120.33
|
| Rate for Payer: HFN Commercial |
$124.38
|
| Rate for Payer: Multiplan Commercial |
$108.16
|
| Rate for Payer: Preferred Network Access Commercial |
$124.38
|
| Rate for Payer: Quartz Beloit One Network |
$66.25
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: WEA Trust Commercial |
$74.36
|
| Rate for Payer: WPS Commercial |
$100.14
|
|
|
NOSEBLEED WOUND SEAL MD NPS861
|
Facility
|
OP
|
$130.00
|
|
| Hospital Charge Code |
3000484
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.86 |
| Max. Negotiated Rate |
$124.38 |
| Rate for Payer: Aetna Commercial |
$121.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.27
|
| Rate for Payer: Aetna Managed Medicare |
$37.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$87.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.66
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$124.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.66
|
| Rate for Payer: Health EOS Commercial |
$120.33
|
| Rate for Payer: HFN Commercial |
$124.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$101.40
|
| Rate for Payer: Multiplan Commercial |
$108.16
|
| Rate for Payer: NAPHCARE Commercial |
$81.12
|
| Rate for Payer: Preferred Network Access Commercial |
$124.38
|
| Rate for Payer: Quartz Beloit One Network |
$66.25
|
| Rate for Payer: Quartz Commercial |
$87.88
|
| Rate for Payer: Quartz Medicare Advantage |
$81.12
|
| Rate for Payer: The Alliance Commercial |
$67.60
|
| Rate for Payer: WEA Trust Commercial |
$74.36
|
| Rate for Payer: WPS Commercial |
$100.14
|
|
|
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 |
$5,194.35 |
| Max. Negotiated Rate |
$9,752.66 |
| Rate for Payer: Aetna Commercial |
$9,540.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,116.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,618.38
|
| Rate for Payer: Cash Price |
$3,057.90
|
| Rate for Payer: Cigna Commercial |
$9,752.66
|
| Rate for Payer: Health EOS Commercial |
$9,434.64
|
| Rate for Payer: HFN Commercial |
$9,752.66
|
| Rate for Payer: Multiplan Commercial |
$8,480.58
|
| Rate for Payer: Preferred Network Access Commercial |
$9,752.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,194.35
|
| Rate for Payer: Quartz Commercial |
$6,360.43
|
| Rate for Payer: WEA Trust Commercial |
$5,830.40
|
| Rate for Payer: WPS Commercial |
$7,851.67
|
|
|
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 |
$9.94 |
| Max. Negotiated Rate |
$9,752.66 |
| Rate for Payer: Aetna Commercial |
$9,540.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,116.62
|
| Rate for Payer: Aetna Managed Medicare |
$2,968.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,890.47
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,300.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,088.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,618.38
|
| Rate for Payer: Cash Price |
$3,057.90
|
| Rate for Payer: Cash Price |
$3,057.90
|
| Rate for Payer: Cigna Commercial |
$9,752.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,932.33
|
| Rate for Payer: Health EOS Commercial |
$9,434.64
|
| Rate for Payer: HFN Commercial |
$9,752.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,950.54
|
| Rate for Payer: Multiplan Commercial |
$8,480.58
|
| Rate for Payer: NAPHCARE Commercial |
$6,360.43
|
| Rate for Payer: Preferred Network Access Commercial |
$9,752.66
|
| Rate for Payer: Quartz Beloit One Network |
$5,194.35
|
| Rate for Payer: Quartz Commercial |
$6,890.47
|
| Rate for Payer: Quartz Medicare Advantage |
$6,360.43
|
| Rate for Payer: The Alliance Commercial |
$9.94
|
| Rate for Payer: WEA Trust Commercial |
$5,830.40
|
| Rate for Payer: WPS Commercial |
$7,851.67
|
|
|
NOZZLE FEMORAL BREAKAWAY 0606-512-000
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
2963181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$188.55 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
NOZZLE FEMORAL BREAKAWAY 0606-512-000
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
2963181
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$107.74 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$107.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.34
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.60
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$230.88
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$250.12
|
| Rate for Payer: Quartz Medicare Advantage |
$230.88
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
NST - Devices and Equipment
|
Facility
|
OP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3052330
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$212.76 |
| Max. Negotiated Rate |
$851.05 |
| Rate for Payer: Aetna Commercial |
$805.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$770.08
|
| Rate for Payer: Aetna Managed Medicare |
$212.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$582.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.81
|
| Rate for Payer: Anthem Medicare Advantage |
$212.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$212.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$212.76
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$823.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$212.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$212.76
|
| Rate for Payer: Health EOS Commercial |
$796.94
|
| Rate for Payer: HFN Commercial |
$823.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$791.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$212.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$212.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$212.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$212.76
|
| Rate for Payer: Multiplan Commercial |
$716.35
|
| Rate for Payer: NAPHCARE Commercial |
$319.14
|
| Rate for Payer: Preferred Network Access Commercial |
$823.80
|
| Rate for Payer: Quartz Beloit One Network |
$438.77
|
| Rate for Payer: Quartz Commercial |
$582.04
|
| Rate for Payer: Quartz Medicare Advantage |
$212.76
|
| Rate for Payer: The Alliance Commercial |
$851.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$212.76
|
| Rate for Payer: United Healthcare PPO |
$671.58
|
| Rate for Payer: WEA Trust Commercial |
$492.49
|
| Rate for Payer: Wellcare Medicare |
$212.76
|
| Rate for Payer: WPS Commercial |
$663.23
|
|
|
NST - Devices and Equipment
|
Facility
|
IP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3052330
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$438.77 |
| Max. Negotiated Rate |
$823.80 |
| Rate for Payer: Aetna Commercial |
$805.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$770.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.58
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$823.80
|
| Rate for Payer: Health EOS Commercial |
$796.94
|
| Rate for Payer: HFN Commercial |
$823.80
|
| Rate for Payer: Multiplan Commercial |
$716.35
|
| Rate for Payer: Preferred Network Access Commercial |
$823.80
|
| Rate for Payer: Quartz Beloit One Network |
$438.77
|
| Rate for Payer: Quartz Commercial |
$537.26
|
| Rate for Payer: WEA Trust Commercial |
$492.49
|
| Rate for Payer: WPS Commercial |
$663.23
|
|
|
NST - Individual Charges
|
Facility
|
IP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3040449
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$438.77 |
| Max. Negotiated Rate |
$823.80 |
| Rate for Payer: Aetna Commercial |
$805.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$770.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.58
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$823.80
|
| Rate for Payer: Health EOS Commercial |
$796.94
|
| Rate for Payer: HFN Commercial |
$823.80
|
| Rate for Payer: Multiplan Commercial |
$716.35
|
| Rate for Payer: Preferred Network Access Commercial |
$823.80
|
| Rate for Payer: Quartz Beloit One Network |
$438.77
|
| Rate for Payer: Quartz Commercial |
$537.26
|
| Rate for Payer: WEA Trust Commercial |
$492.49
|
| Rate for Payer: WPS Commercial |
$663.23
|
|
|
NST - Individual Charges
|
Facility
|
OP
|
$861.00
|
|
|
Service Code
|
CPT 59025
|
| Hospital Charge Code |
3040449
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$212.76 |
| Max. Negotiated Rate |
$851.05 |
| Rate for Payer: Aetna Commercial |
$805.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$770.08
|
| Rate for Payer: Aetna Managed Medicare |
$212.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$582.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$447.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$429.81
|
| Rate for Payer: Anthem Medicare Advantage |
$212.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$212.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$212.76
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cash Price |
$258.30
|
| Rate for Payer: Cigna Commercial |
$823.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$212.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$212.76
|
| Rate for Payer: Health EOS Commercial |
$796.94
|
| Rate for Payer: HFN Commercial |
$823.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$791.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$212.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$212.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$212.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$212.76
|
| Rate for Payer: Multiplan Commercial |
$716.35
|
| Rate for Payer: NAPHCARE Commercial |
$319.14
|
| Rate for Payer: Preferred Network Access Commercial |
$823.80
|
| Rate for Payer: Quartz Beloit One Network |
$438.77
|
| Rate for Payer: Quartz Commercial |
$582.04
|
| Rate for Payer: Quartz Medicare Advantage |
$212.76
|
| Rate for Payer: The Alliance Commercial |
$851.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$212.76
|
| Rate for Payer: United Healthcare PPO |
$671.58
|
| Rate for Payer: WEA Trust Commercial |
$492.49
|
| Rate for Payer: Wellcare Medicare |
$212.76
|
| Rate for Payer: WPS Commercial |
$663.23
|
|
|
N-Telopeptide Cross Links Urine
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
978025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.43 |
| Max. Negotiated Rate |
$237.12 |
| Rate for Payer: Aetna Commercial |
$237.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.66
|
| Rate for Payer: Aetna Managed Medicare |
$19.43
|
| Rate for Payer: Anthem Medicare Advantage |
$19.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.43
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$237.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.43
|
| Rate for Payer: Health EOS Commercial |
$227.14
|
| Rate for Payer: HFN Commercial |
$237.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.43
|
| Rate for Payer: Multiplan Commercial |
$199.68
|
| Rate for Payer: NAPHCARE Commercial |
$29.14
|
| Rate for Payer: Preferred Network Access Commercial |
$237.12
|
| Rate for Payer: Quartz Beloit One Network |
$109.82
|
| Rate for Payer: Quartz Commercial |
$142.27
|
| Rate for Payer: Quartz Medicare Advantage |
$19.43
|
| Rate for Payer: The Alliance Commercial |
$76.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.43
|
| Rate for Payer: WEA Trust Commercial |
$137.28
|
| Rate for Payer: WPS Commercial |
$85.48
|
|
|
N-Telopeptide Cross Links Urine
|
Facility
|
IP
|
$240.00
|
|
|
Service Code
|
CPT 82523
|
| Hospital Charge Code |
978025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.30 |
| Max. Negotiated Rate |
$229.63 |
| Rate for Payer: Aetna Commercial |
$224.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$214.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.29
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$229.63
|
| Rate for Payer: Health EOS Commercial |
$222.14
|
| Rate for Payer: HFN Commercial |
$229.63
|
| Rate for Payer: Multiplan Commercial |
$199.68
|
| Rate for Payer: Preferred Network Access Commercial |
$229.63
|
| Rate for Payer: Quartz Beloit One Network |
$122.30
|
| Rate for Payer: Quartz Commercial |
$149.76
|
| Rate for Payer: WEA Trust Commercial |
$137.28
|
| Rate for Payer: WPS Commercial |
$184.87
|
|
