|
Orthovisc Charge
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Aetna Managed Medicare |
$115.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$567.09
|
| Rate for Payer: Anthem Medicare Advantage |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$115.71
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$115.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$181.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$115.71
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$430.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$115.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$115.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: NAPHCARE Commercial |
$173.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$767.94
|
| Rate for Payer: Quartz Medicare Advantage |
$115.71
|
| Rate for Payer: The Alliance Commercial |
$462.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.71
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: Wellcare Medicare |
$115.71
|
| Rate for Payer: WPS Commercial |
$342.06
|
|
|
Orthovisc Charge
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$1,122.37 |
| Rate for Payer: Aetna Commercial |
$1,122.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Aetna Managed Medicare |
$115.71
|
| Rate for Payer: Anthem Medicare Advantage |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$115.71
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,122.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$115.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.82
|
| Rate for Payer: Health EOS Commercial |
$1,075.11
|
| Rate for Payer: HFN Commercial |
$1,122.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$199.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: NAPHCARE Commercial |
$173.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,122.37
|
| Rate for Payer: Quartz Beloit One Network |
$519.83
|
| Rate for Payer: Quartz Commercial |
$673.42
|
| Rate for Payer: Quartz Medicare Advantage |
$115.71
|
| Rate for Payer: The Alliance Commercial |
$318.20
|
| Rate for Payer: United Healthcare Medicaid |
$115.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.71
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$342.06
|
|
|
Orthovisc Charge
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5587403
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$578.91 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$708.86
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$875.06
|
|
|
Orthovisc Inj Per Dose J7324
|
Professional
|
Both
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$1,122.37 |
| Rate for Payer: Aetna Commercial |
$1,122.37
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Aetna Managed Medicare |
$115.71
|
| Rate for Payer: Anthem Medicare Advantage |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$115.71
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,122.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$115.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.82
|
| Rate for Payer: Health EOS Commercial |
$1,075.11
|
| Rate for Payer: HFN Commercial |
$1,122.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$199.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$199.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: NAPHCARE Commercial |
$173.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,122.37
|
| Rate for Payer: Quartz Beloit One Network |
$519.83
|
| Rate for Payer: Quartz Commercial |
$673.42
|
| Rate for Payer: Quartz Medicare Advantage |
$115.71
|
| Rate for Payer: The Alliance Commercial |
$318.20
|
| Rate for Payer: United Healthcare Medicaid |
$115.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.71
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$342.06
|
|
|
Orthovisc Inj Per Dose J7324
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Aetna Managed Medicare |
$115.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$567.09
|
| Rate for Payer: Anthem Medicare Advantage |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$115.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$115.71
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$115.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$181.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$115.71
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$430.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$115.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$115.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$115.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$115.71
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: NAPHCARE Commercial |
$173.57
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$767.94
|
| Rate for Payer: Quartz Medicare Advantage |
$115.71
|
| Rate for Payer: The Alliance Commercial |
$462.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$115.71
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: Wellcare Medicare |
$115.71
|
| Rate for Payer: WPS Commercial |
$342.06
|
|
|
Orthovisc Inj Per Dose J7324
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
HCPCS J7324
|
| Hospital Charge Code |
5586193
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$578.91 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$708.86
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$875.06
|
|
|
OSCILLATING TRACKING TEST 92545
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
CPT 92545
|
| Hospital Charge Code |
3015335
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$16.54 |
| Max. Negotiated Rate |
$66.14 |
| Rate for Payer: Aetna Commercial |
$48.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$16.54
|
| Rate for Payer: Anthem Medicare Advantage |
$16.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.54
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$48.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.54
|
| Rate for Payer: Health EOS Commercial |
$46.37
|
| Rate for Payer: HFN Commercial |
$48.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.32
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.54
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$24.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.41
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.05
|
| Rate for Payer: Quartz Medicare Advantage |
$16.54
|
| Rate for Payer: The Alliance Commercial |
$41.34
|
| Rate for Payer: United Healthcare Medicaid |
$21.11
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.54
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$66.14
|
|
|
Osmolality
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$62.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$30.25
|
|
|
Osmolality
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
Osmolality
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
633791
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.41
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: United Healthcare PPO |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: Wellcare Medicare |
$6.87
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
Osmolality BF to Mayo
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
4619092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$126.46 |
| Rate for Payer: Aetna Commercial |
$126.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$126.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$121.14
|
| Rate for Payer: HFN Commercial |
$126.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$126.46
|
| Rate for Payer: Quartz Beloit One Network |
$58.57
|
| Rate for Payer: Quartz Commercial |
$75.88
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.15
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$30.25
|
|
|
Osmolality BF to Mayo
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
4619092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$6.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.41
|
| Rate for Payer: Anthem Medicare Advantage |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.87
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.87
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.87
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.87
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.87
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.87
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$10.31
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$6.87
|
| Rate for Payer: The Alliance Commercial |
$27.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.87
|
| Rate for Payer: United Healthcare PPO |
$99.84
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: Wellcare Medicare |
$6.87
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Osmolality BF to Mayo
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
CPT 83930
|
| Hospital Charge Code |
4619092
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Osmolality, Feces
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
4464917
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$54.34 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$54.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.32
|
| Rate for Payer: Health EOS Commercial |
$52.05
|
| Rate for Payer: HFN Commercial |
$54.34
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$54.34
|
| Rate for Payer: Quartz Beloit One Network |
$25.17
|
| Rate for Payer: Quartz Commercial |
$32.60
|
| Rate for Payer: The Alliance Commercial |
$28.60
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
Osmolality, Feces
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
4464917
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
Osmolality, Feces
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
4464917
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.02 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$16.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.18
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.01
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.90
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$34.32
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$34.32
|
| Rate for Payer: The Alliance Commercial |
$28.60
|
| Rate for Payer: United Healthcare PPO |
$42.90
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
Osmolality Urine
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
633792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$7.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.77
|
| Rate for Payer: Anthem Medicare Advantage |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.09
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.09
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$10.64
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$116.95
|
| Rate for Payer: Quartz Medicare Advantage |
$7.09
|
| Rate for Payer: The Alliance Commercial |
$28.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.09
|
| Rate for Payer: United Healthcare PPO |
$134.94
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: Wellcare Medicare |
$7.09
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Osmolality Urine
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
633792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$165.53 |
| Rate for Payer: Aetna Commercial |
$161.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.36
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$165.53
|
| Rate for Payer: Health EOS Commercial |
$160.13
|
| Rate for Payer: HFN Commercial |
$165.53
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: Preferred Network Access Commercial |
$165.53
|
| Rate for Payer: Quartz Beloit One Network |
$88.16
|
| Rate for Payer: Quartz Commercial |
$107.95
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$133.26
|
|
|
Osmolality Urine
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
633792
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$170.92 |
| Rate for Payer: Aetna Commercial |
$170.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$154.73
|
| Rate for Payer: Aetna Managed Medicare |
$7.09
|
| Rate for Payer: Anthem Medicare Advantage |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.09
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$170.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.09
|
| Rate for Payer: Health EOS Commercial |
$163.73
|
| Rate for Payer: HFN Commercial |
$170.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$143.94
|
| Rate for Payer: NAPHCARE Commercial |
$10.64
|
| Rate for Payer: Preferred Network Access Commercial |
$170.92
|
| Rate for Payer: Quartz Beloit One Network |
$79.16
|
| Rate for Payer: Quartz Commercial |
$102.55
|
| Rate for Payer: Quartz Medicare Advantage |
$7.09
|
| Rate for Payer: The Alliance Commercial |
$28.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.09
|
| Rate for Payer: WEA Trust Commercial |
$98.96
|
| Rate for Payer: WPS Commercial |
$31.21
|
|
|
Osmolality, Urine
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
5474697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$7.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.77
|
| Rate for Payer: Anthem Medicare Advantage |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.09
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7.09
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$10.64
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$27.04
|
| Rate for Payer: Quartz Medicare Advantage |
$7.09
|
| Rate for Payer: The Alliance Commercial |
$28.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.09
|
| Rate for Payer: United Healthcare PPO |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: Wellcare Medicare |
$7.09
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
Osmolality, Urine
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
5474697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.38 |
| Max. Negotiated Rate |
$38.27 |
| Rate for Payer: Aetna Commercial |
$37.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$22.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$38.27
|
| Rate for Payer: Health EOS Commercial |
$37.02
|
| Rate for Payer: HFN Commercial |
$38.27
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: Preferred Network Access Commercial |
$38.27
|
| Rate for Payer: Quartz Beloit One Network |
$20.38
|
| Rate for Payer: Quartz Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$30.81
|
|
|
Osmolality, Urine
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
CPT 83935
|
| Hospital Charge Code |
5474697
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$39.52 |
| Rate for Payer: Aetna Commercial |
$39.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$35.78
|
| Rate for Payer: Aetna Managed Medicare |
$7.09
|
| Rate for Payer: Anthem Medicare Advantage |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7.09
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$39.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$20.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.09
|
| Rate for Payer: Health EOS Commercial |
$37.86
|
| Rate for Payer: HFN Commercial |
$39.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7.09
|
| Rate for Payer: Multiplan Commercial |
$33.28
|
| Rate for Payer: NAPHCARE Commercial |
$10.64
|
| Rate for Payer: Preferred Network Access Commercial |
$39.52
|
| Rate for Payer: Quartz Beloit One Network |
$18.30
|
| Rate for Payer: Quartz Commercial |
$23.71
|
| Rate for Payer: Quartz Medicare Advantage |
$7.09
|
| Rate for Payer: The Alliance Commercial |
$28.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7.09
|
| Rate for Payer: WEA Trust Commercial |
$22.88
|
| Rate for Payer: WPS Commercial |
$31.21
|
|
|
Osmolite 1.2 Rth 1000 mL
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
3031446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.58 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Osmolite 1.2 Rth 1000 mL
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
3031446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.47 |
| Max. Negotiated Rate |
$57.41 |
| Rate for Payer: Aetna Commercial |
$56.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.66
|
| Rate for Payer: Aetna Managed Medicare |
$17.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.07
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.92
|
| Rate for Payer: Health EOS Commercial |
$55.54
|
| Rate for Payer: HFN Commercial |
$57.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.80
|
| Rate for Payer: Multiplan Commercial |
$49.92
|
| Rate for Payer: NAPHCARE Commercial |
$37.44
|
| Rate for Payer: Preferred Network Access Commercial |
$57.41
|
| Rate for Payer: Quartz Beloit One Network |
$30.58
|
| Rate for Payer: Quartz Commercial |
$40.56
|
| Rate for Payer: Quartz Medicare Advantage |
$37.44
|
| Rate for Payer: The Alliance Commercial |
$31.20
|
| Rate for Payer: WEA Trust Commercial |
$34.32
|
| Rate for Payer: WPS Commercial |
$46.22
|
|
|
Osmotic Fragility, Red Blood Cell
|
Facility
|
OP
|
$291.00
|
|
|
Service Code
|
CPT 85557
|
| Hospital Charge Code |
978132
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.89 |
| Max. Negotiated Rate |
$278.43 |
| Rate for Payer: Aetna Commercial |
$272.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$260.27
|
| Rate for Payer: Aetna Managed Medicare |
$13.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.06
|
| Rate for Payer: Anthem Medicare Advantage |
$13.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$160.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.89
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$278.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$169.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.89
|
| Rate for Payer: Health EOS Commercial |
$269.35
|
| Rate for Payer: HFN Commercial |
$278.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.89
|
| Rate for Payer: Multiplan Commercial |
$242.11
|
| Rate for Payer: NAPHCARE Commercial |
$20.84
|
| Rate for Payer: Preferred Network Access Commercial |
$278.43
|
| Rate for Payer: Quartz Beloit One Network |
$148.29
|
| Rate for Payer: Quartz Commercial |
$196.72
|
| Rate for Payer: Quartz Medicare Advantage |
$13.89
|
| Rate for Payer: The Alliance Commercial |
$55.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.89
|
| Rate for Payer: United Healthcare PPO |
$226.98
|
| Rate for Payer: WEA Trust Commercial |
$166.45
|
| Rate for Payer: Wellcare Medicare |
$13.89
|
| Rate for Payer: WPS Commercial |
$224.16
|
|
