|
Testosterone Cypionate
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
5593764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.27
|
|
|
Testosterone Cypionate
|
Professional
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
5593764
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Managed Medicare |
$0.03
|
| Rate for Payer: Anthem Medicare Advantage |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: Quartz Medicare Advantage |
$0.03
|
| Rate for Payer: The Alliance Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicaid |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.03
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$109.36 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Managed Medicare |
$0.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.23
|
| Rate for Payer: Quartz Medicare Advantage |
$0.22
|
| Rate for Payer: The Alliance Commercial |
$109.36
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna Commercial |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.19
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.33
|
| Rate for Payer: Health EOS Commercial |
$0.32
|
| Rate for Payer: HFN Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: NAPHCARE Commercial |
$0.22
|
| Rate for Payer: Preferred Network Access Commercial |
$0.33
|
| Rate for Payer: Quartz Beloit One Network |
$0.18
|
| Rate for Payer: Quartz Commercial |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.27
|
|
|
Testosterone Cypionate Inj 1mg J1071
|
Professional
|
$0.36
|
|
|
Service Code
|
HCPCS J1071
|
| Hospital Charge Code |
4498597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna Commercial |
$0.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.31
|
| Rate for Payer: Aetna Managed Medicare |
$0.03
|
| Rate for Payer: Anthem Medicare Advantage |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.03
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna Commercial |
$0.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.01
|
| Rate for Payer: Health EOS Commercial |
$0.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.29
|
| Rate for Payer: Preferred Network Access Commercial |
$0.34
|
| Rate for Payer: Quartz Beloit One Network |
$0.16
|
| Rate for Payer: Quartz Commercial |
$0.21
|
| Rate for Payer: Quartz Medicare Advantage |
$0.03
|
| Rate for Payer: The Alliance Commercial |
$0.08
|
| Rate for Payer: United Healthcare Medicaid |
$0.01
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.03
|
| Rate for Payer: WEA Trust Commercial |
$0.20
|
| Rate for Payer: WPS Commercial |
$0.03
|
|
|
Testosterone Free
|
Professional
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$169.10 |
| Rate for Payer: Aetna Commercial |
$169.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Aetna Managed Medicare |
$25.47
|
| Rate for Payer: Anthem Medicare Advantage |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.47
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$169.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$89.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.47
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.47
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$169.10
|
| Rate for Payer: Quartz Beloit One Network |
$78.32
|
| Rate for Payer: Quartz Commercial |
$101.46
|
| Rate for Payer: Quartz Medicare Advantage |
$25.47
|
| Rate for Payer: The Alliance Commercial |
$100.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.47
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$112.07
|
|
|
Testosterone Free
|
Facility
IP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$87.22 |
| Max. Negotiated Rate |
$163.76 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$106.80
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$106.80
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Testosterone Free
|
Facility
OP
|
$178.00
|
|
|
Service Code
|
CPT 84402
|
| Hospital Charge Code |
2943013
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.47 |
| Max. Negotiated Rate |
$712.00 |
| Rate for Payer: Aetna Commercial |
$160.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.08
|
| Rate for Payer: Aetna Managed Medicare |
$25.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$95.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$44.57
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.28
|
| Rate for Payer: Anthem Medicaid |
$26.32
|
| Rate for Payer: Anthem Medicare Advantage |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.47
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cash Price |
$53.40
|
| Rate for Payer: Cigna Commercial |
$163.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.32
|
| Rate for Payer: Dean Health Medicaid |
$26.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.47
|
| Rate for Payer: Health EOS Commercial |
$158.42
|
| Rate for Payer: HFN Commercial |
$163.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.47
|
| Rate for Payer: Managed Health Services Medicaid |
$27.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.47
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.47
|
| Rate for Payer: Multiplan Commercial |
$142.40
|
| Rate for Payer: NAPHCARE Commercial |
$38.20
|
| Rate for Payer: Preferred Network Access Commercial |
$163.76
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.32
|
| Rate for Payer: Quartz Beloit One Network |
$87.22
|
| Rate for Payer: Quartz Commercial |
$115.70
|
| Rate for Payer: Quartz Medicare Advantage |
$25.47
|
| Rate for Payer: The Alliance Commercial |
$712.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.47
|
| Rate for Payer: United Healthcare PPO |
$133.50
|
| Rate for Payer: WEA Trust Commercial |
$97.90
|
| Rate for Payer: Wellcare Medicare |
$25.47
|
| Rate for Payer: WMAP Medicaid |
$26.32
|
| Rate for Payer: WPS Commercial |
$131.84
|
|
|
Testosterone, Free, Bioavailable & Total
|
Professional
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$101.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$113.56
|
|
|
Testosterone, Free, Bioavailable & Total
|
Facility
IP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone, Free, Bioavailable & Total
|
Facility
OP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983421
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.84
|
| Rate for Payer: Anthem Medicaid |
$26.67
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Managed Health Services Medicaid |
$27.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$38.72
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.67
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: Wellcare Medicare |
$25.81
|
| Rate for Payer: WMAP Medicaid |
$26.67
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone, Free & Total
|
Facility
IP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983420
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone, Free & Total
|
Professional
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983420
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$101.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$113.56
|
|
|
Testosterone, Free & Total
|
Facility
OP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
983420
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.84
|
| Rate for Payer: Anthem Medicaid |
$26.67
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Managed Health Services Medicaid |
$27.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$38.72
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.67
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: Wellcare Medicare |
$25.81
|
| Rate for Payer: WMAP Medicaid |
$26.67
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone Level Total
|
Facility
IP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
633838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone Level Total
|
Professional
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
633838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$101.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$113.56
|
|
|
Testosterone Level Total
|
Facility
OP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
633838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.84
|
| Rate for Payer: Anthem Medicaid |
$26.67
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Managed Health Services Medicaid |
$27.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$38.72
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.67
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: Wellcare Medicare |
$25.81
|
| Rate for Payer: WMAP Medicaid |
$26.67
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone pellet 75 mg S0189
|
Facility
OP
|
$142.00
|
|
| Hospital Charge Code |
3382853
|
| Min. Negotiated Rate |
$39.76 |
| Max. Negotiated Rate |
$568.00 |
| Rate for Payer: Aetna Commercial |
$127.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.12
|
| Rate for Payer: Aetna Managed Medicare |
$39.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$92.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$71.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.26
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$130.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.46
|
| Rate for Payer: Health EOS Commercial |
$126.38
|
| Rate for Payer: HFN Commercial |
$130.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$106.50
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: NAPHCARE Commercial |
$85.20
|
| Rate for Payer: Preferred Network Access Commercial |
$130.64
|
| Rate for Payer: Quartz Beloit One Network |
$69.58
|
| Rate for Payer: Quartz Commercial |
$92.30
|
| Rate for Payer: Quartz Medicare Advantage |
$85.20
|
| Rate for Payer: The Alliance Commercial |
$568.00
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
Testosterone pellet 75 mg S0189
|
Facility
IP
|
$142.00
|
|
| Hospital Charge Code |
3382853
|
| Min. Negotiated Rate |
$69.58 |
| Max. Negotiated Rate |
$130.64 |
| Rate for Payer: Aetna Commercial |
$127.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$75.26
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$130.64
|
| Rate for Payer: Health EOS Commercial |
$126.38
|
| Rate for Payer: HFN Commercial |
$130.64
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: NAPHCARE Commercial |
$85.20
|
| Rate for Payer: Preferred Network Access Commercial |
$130.64
|
| Rate for Payer: Quartz Beloit One Network |
$69.58
|
| Rate for Payer: Quartz Commercial |
$85.20
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
Testosterone pellet 75 mg S0189
|
Professional
|
$142.00
|
|
| Hospital Charge Code |
3382853
|
| Min. Negotiated Rate |
$62.48 |
| Max. Negotiated Rate |
$134.90 |
| Rate for Payer: Aetna Commercial |
$134.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$122.12
|
| Rate for Payer: Cash Price |
$42.60
|
| Rate for Payer: Cigna Commercial |
$134.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.20
|
| Rate for Payer: Health EOS Commercial |
$129.22
|
| Rate for Payer: Multiplan Commercial |
$113.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.90
|
| Rate for Payer: Quartz Beloit One Network |
$62.48
|
| Rate for Payer: Quartz Commercial |
$80.94
|
| Rate for Payer: The Alliance Commercial |
$71.00
|
| Rate for Payer: WEA Trust Commercial |
$78.10
|
| Rate for Payer: WPS Commercial |
$105.18
|
|
|
Testosterone, Total Males
|
Professional
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
4004575
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$309.70 |
| Rate for Payer: Aetna Commercial |
$309.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$309.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$163.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$296.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$91.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: Preferred Network Access Commercial |
$309.70
|
| Rate for Payer: Quartz Beloit One Network |
$143.44
|
| Rate for Payer: Quartz Commercial |
$185.82
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$101.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$113.56
|
|
|
Testosterone, Total Males
|
Facility
OP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
4004575
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.81 |
| Max. Negotiated Rate |
$1,304.00 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$280.36
|
| Rate for Payer: Aetna Managed Medicare |
$25.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$96.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$42.84
|
| Rate for Payer: Anthem Medicaid |
$26.67
|
| Rate for Payer: Anthem Medicare Advantage |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.81
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicaid |
$26.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.81
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.81
|
| Rate for Payer: Managed Health Services Medicaid |
$27.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.81
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$38.72
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26.67
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$211.90
|
| Rate for Payer: Quartz Medicare Advantage |
$25.81
|
| Rate for Payer: The Alliance Commercial |
$1,304.00
|
| Rate for Payer: United Healthcare Medicaid |
$26.67
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.81
|
| Rate for Payer: United Healthcare PPO |
$244.50
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: Wellcare Medicare |
$25.81
|
| Rate for Payer: WMAP Medicaid |
$26.67
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Testosterone, Total Males
|
Facility
IP
|
$326.00
|
|
|
Service Code
|
CPT 84403
|
| Hospital Charge Code |
4004575
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$159.74 |
| Max. Negotiated Rate |
$299.92 |
| Rate for Payer: Aetna Commercial |
$293.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$172.78
|
| Rate for Payer: Cash Price |
$97.80
|
| Rate for Payer: Cigna Commercial |
$299.92
|
| Rate for Payer: Health EOS Commercial |
$290.14
|
| Rate for Payer: HFN Commercial |
$299.92
|
| Rate for Payer: Multiplan Commercial |
$260.80
|
| Rate for Payer: NAPHCARE Commercial |
$195.60
|
| Rate for Payer: Preferred Network Access Commercial |
$299.92
|
| Rate for Payer: Quartz Beloit One Network |
$159.74
|
| Rate for Payer: Quartz Commercial |
$195.60
|
| Rate for Payer: WEA Trust Commercial |
$179.30
|
| Rate for Payer: WPS Commercial |
$241.47
|
|
|
Tetanus AB
|
Facility
OP
|
$131.00
|
|
|
Service Code
|
CPT 86774
|
| Hospital Charge Code |
4510783
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$524.00 |
| Rate for Payer: Aetna Commercial |
$117.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$112.66
|
| Rate for Payer: Aetna Managed Medicare |
$14.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.57
|
| Rate for Payer: Anthem Medicaid |
$15.29
|
| Rate for Payer: Anthem Medicare Advantage |
$14.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.80
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$120.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.29
|
| Rate for Payer: Dean Health Medicaid |
$15.29
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.80
|
| Rate for Payer: Health EOS Commercial |
$116.59
|
| Rate for Payer: HFN Commercial |
$120.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.80
|
| Rate for Payer: Managed Health Services Medicaid |
$15.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.80
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.80
|
| Rate for Payer: Multiplan Commercial |
$104.80
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$120.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.29
|
| Rate for Payer: Quartz Beloit One Network |
$64.19
|
| Rate for Payer: Quartz Commercial |
$85.15
|
| Rate for Payer: Quartz Medicare Advantage |
$14.80
|
| Rate for Payer: The Alliance Commercial |
$524.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.80
|
| Rate for Payer: United Healthcare PPO |
$98.25
|
| Rate for Payer: WEA Trust Commercial |
$72.05
|
| Rate for Payer: Wellcare Medicare |
$14.80
|
| Rate for Payer: WMAP Medicaid |
$15.29
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
|
Tetanus AB
|
Facility
IP
|
$131.00
|
|
|
Service Code
|
CPT 86774
|
| Hospital Charge Code |
4510783
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.19 |
| Max. Negotiated Rate |
$120.52 |
| Rate for Payer: Aetna Commercial |
$117.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$69.43
|
| Rate for Payer: Cash Price |
$39.30
|
| Rate for Payer: Cigna Commercial |
$120.52
|
| Rate for Payer: Health EOS Commercial |
$116.59
|
| Rate for Payer: HFN Commercial |
$120.52
|
| Rate for Payer: Multiplan Commercial |
$104.80
|
| Rate for Payer: NAPHCARE Commercial |
$78.60
|
| Rate for Payer: Preferred Network Access Commercial |
$120.52
|
| Rate for Payer: Quartz Beloit One Network |
$64.19
|
| Rate for Payer: Quartz Commercial |
$78.60
|
| Rate for Payer: WEA Trust Commercial |
$72.05
|
| Rate for Payer: WPS Commercial |
$97.03
|
|
