|
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 Antibody
|
Facility
IP
|
$261.00
|
|
|
Service Code
|
CPT 86774
|
| Hospital Charge Code |
978076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.89 |
| Max. Negotiated Rate |
$240.12 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$138.33
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| Rate for Payer: Health EOS Commercial |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$156.60
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$156.60
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
Tetanus Antibody
|
Professional
|
$261.00
|
|
|
Service Code
|
CPT 86774
|
| Hospital Charge Code |
978076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$247.95 |
| Rate for Payer: Aetna Commercial |
$247.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| Rate for Payer: Aetna Managed Medicare |
$14.80
|
| Rate for Payer: Anthem Medicare Advantage |
$14.80
|
| 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 |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$247.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$130.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.80
|
| Rate for Payer: Health EOS Commercial |
$237.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.80
|
| Rate for Payer: Multiplan Commercial |
$208.80
|
| Rate for Payer: Preferred Network Access Commercial |
$247.95
|
| Rate for Payer: Quartz Beloit One Network |
$114.84
|
| Rate for Payer: Quartz Commercial |
$148.77
|
| Rate for Payer: Quartz Medicare Advantage |
$14.80
|
| Rate for Payer: The Alliance Commercial |
$58.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.80
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: WPS Commercial |
$65.12
|
|
|
Tetanus Antibody
|
Facility
OP
|
$261.00
|
|
|
Service Code
|
CPT 86774
|
| Hospital Charge Code |
978076
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.80 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Aetna Commercial |
$234.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$224.46
|
| 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 |
$138.33
|
| 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 |
$78.30
|
| Rate for Payer: Cash Price |
$78.30
|
| Rate for Payer: Cigna Commercial |
$240.12
|
| 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 |
$232.29
|
| Rate for Payer: HFN Commercial |
$240.12
|
| 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 |
$208.80
|
| Rate for Payer: NAPHCARE Commercial |
$22.20
|
| Rate for Payer: Preferred Network Access Commercial |
$240.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.29
|
| Rate for Payer: Quartz Beloit One Network |
$127.89
|
| Rate for Payer: Quartz Commercial |
$169.65
|
| Rate for Payer: Quartz Medicare Advantage |
$14.80
|
| Rate for Payer: The Alliance Commercial |
$1,044.00
|
| Rate for Payer: United Healthcare Medicaid |
$15.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.80
|
| Rate for Payer: United Healthcare PPO |
$195.75
|
| Rate for Payer: WEA Trust Commercial |
$143.55
|
| Rate for Payer: Wellcare Medicare |
$14.80
|
| Rate for Payer: WMAP Medicaid |
$15.29
|
| Rate for Payer: WPS Commercial |
$193.32
|
|
|
Tetracaine 0.5% Ophth Solution 1ml [Med]
|
Facility
OP
|
$35.00
|
|
| Hospital Charge Code |
2974986
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Aetna Managed Medicare |
$9.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.59
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$22.75
|
| Rate for Payer: Quartz Medicare Advantage |
$21.00
|
| Rate for Payer: The Alliance Commercial |
$140.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Tetracaine 0.5% Ophth Solution 1ml [Med]
|
Facility
IP
|
$35.00
|
|
| Hospital Charge Code |
2974986
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
TE voice prosthesis indwelling - Equipment/Device Used
|
Facility
IP
|
$818.00
|
|
|
Service Code
|
HCPCS L8509
|
| Hospital Charge Code |
3008017
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$400.82 |
| Max. Negotiated Rate |
$752.56 |
| Rate for Payer: Aetna Commercial |
$736.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$433.54
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cigna Commercial |
$752.56
|
| Rate for Payer: Health EOS Commercial |
$728.02
|
| Rate for Payer: HFN Commercial |
$752.56
|
| Rate for Payer: Multiplan Commercial |
$654.40
|
| Rate for Payer: NAPHCARE Commercial |
$490.80
|
| Rate for Payer: Preferred Network Access Commercial |
$752.56
|
| Rate for Payer: Quartz Beloit One Network |
$400.82
|
| Rate for Payer: Quartz Commercial |
$490.80
|
| Rate for Payer: WEA Trust Commercial |
$449.90
|
| Rate for Payer: WPS Commercial |
$605.89
|
|
|
TE voice prosthesis indwelling - Equipment/Device Used
|
Facility
OP
|
$818.00
|
|
|
Service Code
|
HCPCS L8509
|
| Hospital Charge Code |
3008017
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$104.74 |
| Max. Negotiated Rate |
$3,272.00 |
| Rate for Payer: Aetna Commercial |
$736.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$703.48
|
| Rate for Payer: Aetna Managed Medicare |
$229.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$104.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$433.54
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cash Price |
$245.40
|
| Rate for Payer: Cigna Commercial |
$752.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$457.75
|
| Rate for Payer: Health EOS Commercial |
$728.02
|
| Rate for Payer: HFN Commercial |
$752.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$613.50
|
| Rate for Payer: Multiplan Commercial |
$654.40
|
| Rate for Payer: NAPHCARE Commercial |
$490.80
|
| Rate for Payer: Preferred Network Access Commercial |
$752.56
|
| Rate for Payer: Quartz Beloit One Network |
$400.82
|
| Rate for Payer: Quartz Commercial |
$531.70
|
| Rate for Payer: Quartz Medicare Advantage |
$490.80
|
| Rate for Payer: The Alliance Commercial |
$3,272.00
|
| Rate for Payer: WEA Trust Commercial |
$449.90
|
| Rate for Payer: WPS Commercial |
$605.89
|
|
|
TE voice prosthesis PT insert - Equipment/Device Used
|
Facility
IP
|
$310.00
|
|
|
Service Code
|
HCPCS L8507
|
| Hospital Charge Code |
3008018
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$151.90 |
| Max. Negotiated Rate |
$285.20 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$186.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$186.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
TE voice prosthesis PT insert - Equipment/Device Used
|
Facility
OP
|
$310.00
|
|
|
Service Code
|
HCPCS L8507
|
| Hospital Charge Code |
3008018
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$40.16 |
| Max. Negotiated Rate |
$1,240.00 |
| Rate for Payer: Aetna Commercial |
$279.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$266.60
|
| Rate for Payer: Aetna Managed Medicare |
$86.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$164.30
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$285.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$173.48
|
| Rate for Payer: Health EOS Commercial |
$275.90
|
| Rate for Payer: HFN Commercial |
$285.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$248.00
|
| Rate for Payer: NAPHCARE Commercial |
$186.00
|
| Rate for Payer: Preferred Network Access Commercial |
$285.20
|
| Rate for Payer: Quartz Beloit One Network |
$151.90
|
| Rate for Payer: Quartz Commercial |
$201.50
|
| Rate for Payer: Quartz Medicare Advantage |
$186.00
|
| Rate for Payer: The Alliance Commercial |
$1,240.00
|
| Rate for Payer: WEA Trust Commercial |
$170.50
|
| Rate for Payer: WPS Commercial |
$229.62
|
|
|
tezepelumab (Tezspire) 210 mg/1.9 mL J2356
|
Facility
OP
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6180528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$7,362.76 |
| Rate for Payer: Aetna Commercial |
$7,202.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,882.58
|
| Rate for Payer: Aetna Managed Medicare |
$18.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,201.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,001.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,841.44
|
| Rate for Payer: Anthem Medicare Advantage |
$18.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,241.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.59
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,362.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.59
|
| Rate for Payer: Health EOS Commercial |
$7,122.67
|
| Rate for Payer: HFN Commercial |
$7,362.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.59
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$27.88
|
| Rate for Payer: Preferred Network Access Commercial |
$7,362.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,921.47
|
| Rate for Payer: Quartz Commercial |
$5,201.95
|
| Rate for Payer: Quartz Medicare Advantage |
$18.59
|
| Rate for Payer: The Alliance Commercial |
$1,408.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.59
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: Wellcare Medicare |
$18.59
|
| Rate for Payer: WPS Commercial |
$44.50
|
|
|
tezepelumab (Tezspire) 210 mg/1.9 mL J2356
|
Facility
IP
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6180528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,921.47 |
| Max. Negotiated Rate |
$7,362.76 |
| Rate for Payer: Aetna Commercial |
$7,202.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,241.59
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,362.76
|
| Rate for Payer: Health EOS Commercial |
$7,122.67
|
| Rate for Payer: HFN Commercial |
$7,362.76
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,801.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,362.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,921.47
|
| Rate for Payer: Quartz Commercial |
$4,801.80
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: WPS Commercial |
$5,927.82
|
|
|
tezepelumab (Tezspire) 210 mg/1.9 mL J2356
|
Professional
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6180528
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$7,602.85 |
| Rate for Payer: Aetna Commercial |
$7,602.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,882.58
|
| Rate for Payer: Aetna Managed Medicare |
$18.73
|
| Rate for Payer: Anthem Medicare Advantage |
$18.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.73
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,602.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,001.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.80
|
| Rate for Payer: Health EOS Commercial |
$7,282.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.73
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,602.85
|
| Rate for Payer: Quartz Beloit One Network |
$3,521.32
|
| Rate for Payer: Quartz Commercial |
$4,561.71
|
| Rate for Payer: Quartz Medicare Advantage |
$18.73
|
| Rate for Payer: The Alliance Commercial |
$51.50
|
| Rate for Payer: United Healthcare Medicaid |
$17.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.73
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: WPS Commercial |
$44.50
|
|
|
Tezspire Charge
|
Professional
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6181580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.80 |
| Max. Negotiated Rate |
$7,602.85 |
| Rate for Payer: Aetna Commercial |
$7,602.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,882.58
|
| Rate for Payer: Aetna Managed Medicare |
$18.73
|
| Rate for Payer: Anthem Medicare Advantage |
$18.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.73
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,602.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,001.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.80
|
| Rate for Payer: Health EOS Commercial |
$7,282.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.73
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: Preferred Network Access Commercial |
$7,602.85
|
| Rate for Payer: Quartz Beloit One Network |
$3,521.32
|
| Rate for Payer: Quartz Commercial |
$4,561.71
|
| Rate for Payer: Quartz Medicare Advantage |
$18.73
|
| Rate for Payer: The Alliance Commercial |
$51.50
|
| Rate for Payer: United Healthcare Medicaid |
$17.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.73
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: WPS Commercial |
$44.50
|
|
|
Tezspire Charge
|
Facility
IP
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6181580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,921.47 |
| Max. Negotiated Rate |
$7,362.76 |
| Rate for Payer: Aetna Commercial |
$7,202.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,241.59
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,362.76
|
| Rate for Payer: Health EOS Commercial |
$7,122.67
|
| Rate for Payer: HFN Commercial |
$7,362.76
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,801.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,362.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,921.47
|
| Rate for Payer: Quartz Commercial |
$4,801.80
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: WPS Commercial |
$5,927.82
|
|
|
Tezspire Charge
|
Facility
OP
|
$8,003.00
|
|
|
Service Code
|
HCPCS J2356
|
| Hospital Charge Code |
6181580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$7,362.76 |
| Rate for Payer: Aetna Commercial |
$7,202.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,882.58
|
| Rate for Payer: Aetna Managed Medicare |
$18.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,201.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,001.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,841.44
|
| Rate for Payer: Anthem Medicare Advantage |
$18.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,241.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.59
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cash Price |
$2,400.90
|
| Rate for Payer: Cigna Commercial |
$7,362.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$23.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.59
|
| Rate for Payer: Health EOS Commercial |
$7,122.67
|
| Rate for Payer: HFN Commercial |
$7,362.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.59
|
| Rate for Payer: Multiplan Commercial |
$6,402.40
|
| Rate for Payer: NAPHCARE Commercial |
$27.88
|
| Rate for Payer: Preferred Network Access Commercial |
$7,362.76
|
| Rate for Payer: Quartz Beloit One Network |
$3,921.47
|
| Rate for Payer: Quartz Commercial |
$5,201.95
|
| Rate for Payer: Quartz Medicare Advantage |
$18.59
|
| Rate for Payer: The Alliance Commercial |
$1,408.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.59
|
| Rate for Payer: WEA Trust Commercial |
$4,401.65
|
| Rate for Payer: Wellcare Medicare |
$18.59
|
| Rate for Payer: WPS Commercial |
$44.50
|
|
|
Thalassemia & Hemoglobinopathy Comprehensive
|
Facility
OP
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$397.08 |
| Rate for Payer: Quartz Beloit One Network |
$48.64
|
| Rate for Payer: Aetna Commercial |
$89.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.37
|
| Rate for Payer: Aetna Managed Medicare |
$13.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.63
|
| Rate for Payer: Anthem Medicaid |
$14.08
|
| Rate for Payer: Anthem Medicare Advantage |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.63
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$91.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.08
|
| Rate for Payer: Dean Health Medicaid |
$14.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.63
|
| Rate for Payer: Health EOS Commercial |
$88.35
|
| Rate for Payer: HFN Commercial |
$91.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.63
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.63
|
| Rate for Payer: Managed Health Services Medicaid |
$14.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.63
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: NAPHCARE Commercial |
$20.44
|
| Rate for Payer: Preferred Network Access Commercial |
$91.33
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.08
|
| Rate for Payer: Quartz Commercial |
$64.53
|
| Rate for Payer: Quartz Medicare Advantage |
$13.63
|
| Rate for Payer: The Alliance Commercial |
$397.08
|
| Rate for Payer: United Healthcare Medicaid |
$14.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.63
|
| Rate for Payer: United Healthcare PPO |
$74.45
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: Wellcare Medicare |
$13.63
|
| Rate for Payer: WMAP Medicaid |
$14.08
|
| Rate for Payer: WPS Commercial |
$73.53
|
|
|
Thalassemia & Hemoglobinopathy Comprehensive
|
Professional
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$94.31 |
| Rate for Payer: Aetna Commercial |
$94.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.37
|
| Rate for Payer: Aetna Managed Medicare |
$13.63
|
| Rate for Payer: Anthem Medicare Advantage |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.63
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$94.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$49.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.63
|
| Rate for Payer: Health EOS Commercial |
$90.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.63
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: Preferred Network Access Commercial |
$94.31
|
| Rate for Payer: Quartz Beloit One Network |
$43.68
|
| Rate for Payer: Quartz Commercial |
$56.58
|
| Rate for Payer: Quartz Medicare Advantage |
$13.63
|
| Rate for Payer: The Alliance Commercial |
$53.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.63
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: WPS Commercial |
$59.97
|
|
|
Thalassemia & Hemoglobinopathy Comprehensive
|
Facility
IP
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.64 |
| Max. Negotiated Rate |
$91.33 |
| Rate for Payer: Aetna Commercial |
$89.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.61
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$91.33
|
| Rate for Payer: Health EOS Commercial |
$88.35
|
| Rate for Payer: HFN Commercial |
$91.33
|
| Rate for Payer: Multiplan Commercial |
$79.42
|
| Rate for Payer: NAPHCARE Commercial |
$59.56
|
| Rate for Payer: Preferred Network Access Commercial |
$91.33
|
| Rate for Payer: Quartz Beloit One Network |
$48.64
|
| Rate for Payer: Quartz Commercial |
$59.56
|
| Rate for Payer: WEA Trust Commercial |
$54.60
|
| Rate for Payer: WPS Commercial |
$73.53
|
|
|
Thalass Interp
|
Facility
IP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.21 |
| Max. Negotiated Rate |
$118.68 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$77.40
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$77.40
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Thalass Interp
|
Professional
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$18.06
|
| Rate for Payer: Anthem Medicare Advantage |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.06
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$122.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.06
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.06
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$122.55
|
| Rate for Payer: Quartz Beloit One Network |
$56.76
|
| Rate for Payer: Quartz Commercial |
$73.53
|
| Rate for Payer: Quartz Medicare Advantage |
$18.06
|
| Rate for Payer: The Alliance Commercial |
$71.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.06
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$79.46
|
|
|
Thalass Interp
|
Facility
OP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.06 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$116.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| Rate for Payer: Aetna Managed Medicare |
$18.06
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.98
|
| Rate for Payer: Anthem Medicaid |
$18.66
|
| Rate for Payer: Anthem Medicare Advantage |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.06
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$118.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.66
|
| Rate for Payer: Dean Health Medicaid |
$18.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.06
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.18
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.06
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.06
|
| Rate for Payer: Managed Health Services Medicaid |
$19.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.06
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.06
|
| Rate for Payer: Multiplan Commercial |
$103.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.09
|
| Rate for Payer: Preferred Network Access Commercial |
$118.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.66
|
| Rate for Payer: Quartz Beloit One Network |
$63.21
|
| Rate for Payer: Quartz Commercial |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$18.06
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: United Healthcare Medicaid |
$18.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.06
|
| Rate for Payer: United Healthcare PPO |
$96.75
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: Wellcare Medicare |
$18.06
|
| Rate for Payer: WMAP Medicaid |
$18.66
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
Thallium-201(per mCi)
|
Professional
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.23 |
| Max. Negotiated Rate |
$121.60 |
| Rate for Payer: Aetna Commercial |
$121.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.08
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$121.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$64.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$76.80
|
| Rate for Payer: Health EOS Commercial |
$116.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.23
|
| Rate for Payer: Multiplan Commercial |
$102.40
|
| Rate for Payer: Preferred Network Access Commercial |
$121.60
|
| Rate for Payer: Quartz Beloit One Network |
$56.32
|
| Rate for Payer: Quartz Commercial |
$72.96
|
| Rate for Payer: The Alliance Commercial |
$64.00
|
| Rate for Payer: WEA Trust Commercial |
$70.40
|
| Rate for Payer: WPS Commercial |
$94.81
|
|
|
Thallium-201(per mCi)
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.80 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$108.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$110.40
|
| Rate for Payer: Health EOS Commercial |
$106.80
|
| Rate for Payer: HFN Commercial |
$110.40
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: NAPHCARE Commercial |
$72.00
|
| Rate for Payer: Preferred Network Access Commercial |
$110.40
|
| Rate for Payer: Quartz Beloit One Network |
$58.80
|
| Rate for Payer: Quartz Commercial |
$72.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
|
Thallium-201(per mCi)
|
Professional
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$52.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: Aetna Commercial |
$114.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$103.20
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.00
|
| Rate for Payer: Health EOS Commercial |
$109.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.23
|
| Rate for Payer: Multiplan Commercial |
$96.00
|
| Rate for Payer: Preferred Network Access Commercial |
$114.00
|
| Rate for Payer: Quartz Beloit One Network |
$52.80
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$60.00
|
| Rate for Payer: WEA Trust Commercial |
$66.00
|
| Rate for Payer: WPS Commercial |
$88.88
|
|
