|
Surgicel 3 x 4" [Med]"
|
Facility
|
IP
|
$379.00
|
|
| Hospital Charge Code |
2974985
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$193.14 |
| Max. Negotiated Rate |
$362.63 |
| Rate for Payer: Aetna Commercial |
$354.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.90
|
| Rate for Payer: Cash Price |
$113.70
|
| Rate for Payer: Cigna Commercial |
$362.63
|
| Rate for Payer: Health EOS Commercial |
$350.80
|
| Rate for Payer: HFN Commercial |
$362.63
|
| Rate for Payer: Multiplan Commercial |
$315.33
|
| Rate for Payer: Preferred Network Access Commercial |
$362.63
|
| Rate for Payer: Quartz Beloit One Network |
$193.14
|
| Rate for Payer: Quartz Commercial |
$236.50
|
| Rate for Payer: WEA Trust Commercial |
$216.79
|
| Rate for Payer: WPS Commercial |
$291.94
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
OP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$135.99 |
| Max. Negotiated Rate |
$446.83 |
| Rate for Payer: Aetna Commercial |
$437.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.68
|
| Rate for Payer: Aetna Managed Medicare |
$135.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$315.69
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$242.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$233.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.41
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$446.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.79
|
| Rate for Payer: Health EOS Commercial |
$432.26
|
| Rate for Payer: HFN Commercial |
$446.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$364.26
|
| Rate for Payer: Multiplan Commercial |
$388.54
|
| Rate for Payer: NAPHCARE Commercial |
$291.41
|
| Rate for Payer: Preferred Network Access Commercial |
$446.83
|
| Rate for Payer: Quartz Beloit One Network |
$237.98
|
| Rate for Payer: Quartz Commercial |
$315.69
|
| Rate for Payer: Quartz Medicare Advantage |
$291.41
|
| Rate for Payer: The Alliance Commercial |
$242.84
|
| Rate for Payer: WEA Trust Commercial |
$267.12
|
| Rate for Payer: WPS Commercial |
$359.73
|
|
|
SURGICEL 5 X 2 HEMOSTAT"
|
Facility
|
IP
|
$467.00
|
|
| Hospital Charge Code |
2974442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$237.98 |
| Max. Negotiated Rate |
$446.83 |
| Rate for Payer: Aetna Commercial |
$437.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$417.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$257.41
|
| Rate for Payer: Cash Price |
$140.10
|
| Rate for Payer: Cigna Commercial |
$446.83
|
| Rate for Payer: Health EOS Commercial |
$432.26
|
| Rate for Payer: HFN Commercial |
$446.83
|
| Rate for Payer: Multiplan Commercial |
$388.54
|
| Rate for Payer: Preferred Network Access Commercial |
$446.83
|
| Rate for Payer: Quartz Beloit One Network |
$237.98
|
| Rate for Payer: Quartz Commercial |
$291.41
|
| Rate for Payer: WEA Trust Commercial |
$267.12
|
| Rate for Payer: WPS Commercial |
$359.73
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
IP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$205.88 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$252.10
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
SURGICEL FIBRILLAR 1 X 2" 1961"
|
Facility
|
OP
|
$404.00
|
|
| Hospital Charge Code |
4595417
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$117.64 |
| Max. Negotiated Rate |
$386.55 |
| Rate for Payer: Aetna Commercial |
$378.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$361.34
|
| Rate for Payer: Aetna Managed Medicare |
$117.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$273.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$210.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$201.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$222.68
|
| Rate for Payer: Cash Price |
$121.20
|
| Rate for Payer: Cigna Commercial |
$386.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.13
|
| Rate for Payer: Health EOS Commercial |
$373.94
|
| Rate for Payer: HFN Commercial |
$386.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$315.12
|
| Rate for Payer: Multiplan Commercial |
$336.13
|
| Rate for Payer: NAPHCARE Commercial |
$252.10
|
| Rate for Payer: Preferred Network Access Commercial |
$386.55
|
| Rate for Payer: Quartz Beloit One Network |
$205.88
|
| Rate for Payer: Quartz Commercial |
$273.10
|
| Rate for Payer: Quartz Medicare Advantage |
$252.10
|
| Rate for Payer: The Alliance Commercial |
$210.08
|
| Rate for Payer: WEA Trust Commercial |
$231.09
|
| Rate for Payer: WPS Commercial |
$311.20
|
|
|
SURGICLIP LARGE 134048
|
Facility
|
OP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$370.99 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Aetna Managed Medicare |
$370.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$662.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$635.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$741.47
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$993.72
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: NAPHCARE Commercial |
$794.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$861.22
|
| Rate for Payer: Quartz Medicare Advantage |
$794.98
|
| Rate for Payer: The Alliance Commercial |
$662.48
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
SURGICLIP LARGE 134048
|
Facility
|
IP
|
$1,274.00
|
|
| Hospital Charge Code |
2962951
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$649.23 |
| Max. Negotiated Rate |
$1,218.96 |
| Rate for Payer: Aetna Commercial |
$1,192.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,139.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.23
|
| Rate for Payer: Cash Price |
$382.20
|
| Rate for Payer: Cigna Commercial |
$1,218.96
|
| Rate for Payer: Health EOS Commercial |
$1,179.21
|
| Rate for Payer: HFN Commercial |
$1,218.96
|
| Rate for Payer: Multiplan Commercial |
$1,059.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,218.96
|
| Rate for Payer: Quartz Beloit One Network |
$649.23
|
| Rate for Payer: Quartz Commercial |
$794.98
|
| Rate for Payer: WEA Trust Commercial |
$728.73
|
| Rate for Payer: WPS Commercial |
$981.36
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
|
OP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$380.89 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Aetna Managed Medicare |
$380.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$884.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$680.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$652.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$761.26
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,020.24
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: NAPHCARE Commercial |
$816.19
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$884.21
|
| Rate for Payer: Quartz Medicare Advantage |
$816.19
|
| Rate for Payer: The Alliance Commercial |
$680.16
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
|
SURGICLIP MEDIUM 134031
|
Facility
|
IP
|
$1,308.00
|
|
| Hospital Charge Code |
2962932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$666.56 |
| Max. Negotiated Rate |
$1,251.49 |
| Rate for Payer: Aetna Commercial |
$1,224.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,169.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$720.97
|
| Rate for Payer: Cash Price |
$392.40
|
| Rate for Payer: Cigna Commercial |
$1,251.49
|
| Rate for Payer: Health EOS Commercial |
$1,210.68
|
| Rate for Payer: HFN Commercial |
$1,251.49
|
| Rate for Payer: Multiplan Commercial |
$1,088.26
|
| Rate for Payer: Preferred Network Access Commercial |
$1,251.49
|
| Rate for Payer: Quartz Beloit One Network |
$666.56
|
| Rate for Payer: Quartz Commercial |
$816.19
|
| Rate for Payer: WEA Trust Commercial |
$748.18
|
| Rate for Payer: WPS Commercial |
$1,007.55
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
|
IP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SURGIFOAM 1974 (MED)
|
Facility
|
OP
|
$115.00
|
|
| Hospital Charge Code |
5831803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$33.49 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$33.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.70
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$71.76
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$71.76
|
| Rate for Payer: The Alliance Commercial |
$59.80
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
|
IP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$365.89 |
| Max. Negotiated Rate |
$686.98 |
| Rate for Payer: Aetna Commercial |
$672.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.76
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$686.98
|
| Rate for Payer: Health EOS Commercial |
$664.58
|
| Rate for Payer: HFN Commercial |
$686.98
|
| Rate for Payer: Multiplan Commercial |
$597.38
|
| Rate for Payer: Preferred Network Access Commercial |
$686.98
|
| Rate for Payer: Quartz Beloit One Network |
$365.89
|
| Rate for Payer: Quartz Commercial |
$448.03
|
| Rate for Payer: WEA Trust Commercial |
$410.70
|
| Rate for Payer: WPS Commercial |
$553.08
|
|
|
SURGIFOAM POWDER 1978 (MED)
|
Facility
|
OP
|
$718.00
|
|
| Hospital Charge Code |
6246271
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$209.08 |
| Max. Negotiated Rate |
$686.98 |
| Rate for Payer: Aetna Commercial |
$672.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.18
|
| Rate for Payer: Aetna Managed Medicare |
$209.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$485.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$373.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$358.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.76
|
| Rate for Payer: Cash Price |
$215.40
|
| Rate for Payer: Cigna Commercial |
$686.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$417.88
|
| Rate for Payer: Health EOS Commercial |
$664.58
|
| Rate for Payer: HFN Commercial |
$686.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$560.04
|
| Rate for Payer: Multiplan Commercial |
$597.38
|
| Rate for Payer: NAPHCARE Commercial |
$448.03
|
| Rate for Payer: Preferred Network Access Commercial |
$686.98
|
| Rate for Payer: Quartz Beloit One Network |
$365.89
|
| Rate for Payer: Quartz Commercial |
$485.37
|
| Rate for Payer: Quartz Medicare Advantage |
$448.03
|
| Rate for Payer: The Alliance Commercial |
$373.36
|
| Rate for Payer: WEA Trust Commercial |
$410.70
|
| Rate for Payer: WPS Commercial |
$553.08
|
|
|
SURGILUBE JELLY 2 OZ. TUBE 0281-0205-12
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS A4332
|
| Hospital Charge Code |
2968920
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Aetna Managed Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.84
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: NAPHCARE Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$18.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
SURGILUBE JELLY 2 OZ. TUBE 0281-0205-12
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS A4332
|
| Hospital Charge Code |
2968920
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$99.88 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$122.30
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Susceptibility, Aerobic to Mayo
|
Facility
|
OP
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$187.53 |
| Rate for Payer: Aetna Commercial |
$183.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.93
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$108.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$187.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$181.42
|
| Rate for Payer: HFN Commercial |
$187.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$187.53
|
| Rate for Payer: Quartz Beloit One Network |
$99.88
|
| Rate for Payer: Quartz Commercial |
$132.50
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: United Healthcare PPO |
$152.88
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: Wellcare Medicare |
$9.00
|
| Rate for Payer: WPS Commercial |
$150.98
|
|
|
Susceptibility, Aerobic to Mayo
|
Professional
|
Both
|
$196.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
4620678
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$193.65 |
| Rate for Payer: Aetna Commercial |
$193.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$175.30
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cash Price |
$58.80
|
| Rate for Payer: Cigna Commercial |
$193.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$101.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$185.49
|
| Rate for Payer: HFN Commercial |
$193.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$163.07
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$193.65
|
| Rate for Payer: Quartz Beloit One Network |
$89.69
|
| Rate for Payer: Quartz Commercial |
$116.19
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$112.11
|
| Rate for Payer: WPS Commercial |
$39.58
|
|
|
Susceptibility, Anaerobic
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
CPT 87181
|
| Hospital Charge Code |
4732609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$4.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.20
|
| Rate for Payer: Anthem Medicare Advantage |
$4.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.94
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.94
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.94
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$7.41
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: Quartz Medicare Advantage |
$4.94
|
| Rate for Payer: The Alliance Commercial |
$19.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.94
|
| Rate for Payer: United Healthcare PPO |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: Wellcare Medicare |
$4.94
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Susceptibility, Anaerobic
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
CPT 87181
|
| Hospital Charge Code |
4732609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.69 |
| Max. Negotiated Rate |
$68.89 |
| Rate for Payer: Aetna Commercial |
$67.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$39.69
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$68.89
|
| Rate for Payer: Health EOS Commercial |
$66.64
|
| Rate for Payer: HFN Commercial |
$68.89
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$68.89
|
| Rate for Payer: Quartz Beloit One Network |
$36.69
|
| Rate for Payer: Quartz Commercial |
$44.93
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$55.46
|
|
|
Susceptibility, Anaerobic
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
CPT 87181
|
| Hospital Charge Code |
4732609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$71.14 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$64.40
|
| Rate for Payer: Aetna Managed Medicare |
$4.94
|
| Rate for Payer: Anthem Medicare Advantage |
$4.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.94
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cigna Commercial |
$71.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$37.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.94
|
| Rate for Payer: Health EOS Commercial |
$68.14
|
| Rate for Payer: HFN Commercial |
$71.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.94
|
| Rate for Payer: Multiplan Commercial |
$59.90
|
| Rate for Payer: NAPHCARE Commercial |
$7.41
|
| Rate for Payer: Preferred Network Access Commercial |
$71.14
|
| Rate for Payer: Quartz Beloit One Network |
$32.95
|
| Rate for Payer: Quartz Commercial |
$42.68
|
| Rate for Payer: Quartz Medicare Advantage |
$4.94
|
| Rate for Payer: The Alliance Commercial |
$19.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.94
|
| Rate for Payer: WEA Trust Commercial |
$41.18
|
| Rate for Payer: WPS Commercial |
$21.74
|
|
|
Susceptibility Nocardia species
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5390642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$55.04 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$67.39
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
Susceptibility Nocardia species
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5390642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$103.33 |
| Rate for Payer: Aetna Commercial |
$101.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.93
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$59.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$103.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$62.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$99.96
|
| Rate for Payer: HFN Commercial |
$103.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$103.33
|
| Rate for Payer: Quartz Beloit One Network |
$55.04
|
| Rate for Payer: Quartz Commercial |
$73.01
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: United Healthcare PPO |
$84.24
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: Wellcare Medicare |
$9.00
|
| Rate for Payer: WPS Commercial |
$83.19
|
|
|
Susceptibility Nocardia species
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
5390642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$106.70 |
| Rate for Payer: Aetna Commercial |
$106.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$96.60
|
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$106.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$56.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.00
|
| Rate for Payer: Health EOS Commercial |
$102.21
|
| Rate for Payer: HFN Commercial |
$106.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Multiplan Commercial |
$89.86
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Preferred Network Access Commercial |
$106.70
|
| Rate for Payer: Quartz Beloit One Network |
$49.42
|
| Rate for Payer: Quartz Commercial |
$64.02
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.53
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$61.78
|
| Rate for Payer: WPS Commercial |
$39.58
|
|
|
Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate
|
Facility
|
OP
|
$35.98
|
|
|
Service Code
|
CPT 87186
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$35.98 |
| Rate for Payer: Aetna Managed Medicare |
$9.00
|
| Rate for Payer: Anthem Medicare Advantage |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.00
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.00
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.00
|
| Rate for Payer: NAPHCARE Commercial |
$13.49
|
| Rate for Payer: Quartz Medicare Advantage |
$9.00
|
| Rate for Payer: The Alliance Commercial |
$35.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.00
|
| Rate for Payer: Wellcare Medicare |
$9.00
|
|
