|
TISSUE EXPANDER 450CC 354213
|
Facility
IP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,483.99 |
| Max. Negotiated Rate |
$8,418.92 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,490.60
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
TISSUE EXPANDER 450CC 354213
|
Facility
OP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,562.28 |
| Max. Negotiated Rate |
$36,604.00 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,869.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,562.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,948.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,575.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,392.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,120.90
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,863.25
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,948.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,490.60
|
| Rate for Payer: The Alliance Commercial |
$36,604.00
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
TISSUE EXPANDER NATRELLE STYLE 133V 450CC 133FX-12
|
Facility
OP
|
$8,512.00
|
|
| Hospital Charge Code |
2964628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,383.36 |
| Max. Negotiated Rate |
$34,048.00 |
| Rate for Payer: Aetna Commercial |
$7,660.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,320.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,383.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,532.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,256.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,085.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.36
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$7,831.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,763.32
|
| Rate for Payer: Health EOS Commercial |
$7,575.68
|
| Rate for Payer: HFN Commercial |
$7,831.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,384.00
|
| Rate for Payer: Multiplan Commercial |
$6,809.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,107.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,831.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,170.88
|
| Rate for Payer: Quartz Commercial |
$5,532.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,107.20
|
| Rate for Payer: The Alliance Commercial |
$34,048.00
|
| Rate for Payer: WEA Trust Commercial |
$4,681.60
|
| Rate for Payer: WPS Commercial |
$6,304.84
|
|
|
TISSUE EXPANDER NATRELLE STYLE 133V 450CC 133FX-12
|
Facility
IP
|
$8,512.00
|
|
| Hospital Charge Code |
2964628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,170.88 |
| Max. Negotiated Rate |
$7,831.04 |
| Rate for Payer: Aetna Commercial |
$7,660.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,511.36
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$7,831.04
|
| Rate for Payer: Health EOS Commercial |
$7,575.68
|
| Rate for Payer: HFN Commercial |
$7,831.04
|
| Rate for Payer: Multiplan Commercial |
$6,809.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,107.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,831.04
|
| Rate for Payer: Quartz Beloit One Network |
$4,170.88
|
| Rate for Payer: Quartz Commercial |
$5,107.20
|
| Rate for Payer: WEA Trust Commercial |
$4,681.60
|
| Rate for Payer: WPS Commercial |
$6,304.84
|
|
|
TISSUE EXPANDER TISSUE 350CC 354212
|
Facility
IP
|
$9,151.00
|
|
| Hospital Charge Code |
2965395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,483.99 |
| Max. Negotiated Rate |
$8,418.92 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,490.60
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
TISSUE EXPANDER TISSUE 350CC 354212
|
Facility
OP
|
$9,151.00
|
|
| Hospital Charge Code |
2965395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,562.28 |
| Max. Negotiated Rate |
$36,604.00 |
| Rate for Payer: Aetna Commercial |
$8,235.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,869.86
|
| Rate for Payer: Aetna Managed Medicare |
$2,562.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,948.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,575.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,392.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,850.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,418.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,120.90
|
| Rate for Payer: Health EOS Commercial |
$8,144.39
|
| Rate for Payer: HFN Commercial |
$8,418.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,863.25
|
| Rate for Payer: Multiplan Commercial |
$7,320.80
|
| Rate for Payer: NAPHCARE Commercial |
$5,490.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8,418.92
|
| Rate for Payer: Quartz Beloit One Network |
$4,483.99
|
| Rate for Payer: Quartz Commercial |
$5,948.15
|
| Rate for Payer: Quartz Medicare Advantage |
$5,490.60
|
| Rate for Payer: The Alliance Commercial |
$36,604.00
|
| Rate for Payer: WEA Trust Commercial |
$5,033.05
|
| Rate for Payer: WPS Commercial |
$6,778.15
|
|
|
TISSUE MARKER ULTRA CLIP #861017
|
Facility
IP
|
$1,666.00
|
|
| Hospital Charge Code |
2973592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$816.34 |
| Max. Negotiated Rate |
$1,532.72 |
| Rate for Payer: Aetna Commercial |
$1,499.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$882.98
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,532.72
|
| Rate for Payer: Health EOS Commercial |
$1,482.74
|
| Rate for Payer: HFN Commercial |
$1,532.72
|
| Rate for Payer: Multiplan Commercial |
$1,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$999.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.72
|
| Rate for Payer: Quartz Beloit One Network |
$816.34
|
| Rate for Payer: Quartz Commercial |
$999.60
|
| Rate for Payer: WEA Trust Commercial |
$916.30
|
| Rate for Payer: WPS Commercial |
$1,234.01
|
|
|
TISSUE MARKER ULTRA CLIP #861017
|
Facility
OP
|
$1,666.00
|
|
| Hospital Charge Code |
2973592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$466.48 |
| Max. Negotiated Rate |
$6,664.00 |
| Rate for Payer: Aetna Commercial |
$1,499.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,432.76
|
| Rate for Payer: Aetna Managed Medicare |
$466.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,082.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$833.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$799.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$882.98
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,532.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$932.29
|
| Rate for Payer: Health EOS Commercial |
$1,482.74
|
| Rate for Payer: HFN Commercial |
$1,532.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,249.50
|
| Rate for Payer: Multiplan Commercial |
$1,332.80
|
| Rate for Payer: NAPHCARE Commercial |
$999.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,532.72
|
| Rate for Payer: Quartz Beloit One Network |
$816.34
|
| Rate for Payer: Quartz Commercial |
$1,082.90
|
| Rate for Payer: Quartz Medicare Advantage |
$999.60
|
| Rate for Payer: The Alliance Commercial |
$6,664.00
|
| Rate for Payer: WEA Trust Commercial |
$916.30
|
| Rate for Payer: WPS Commercial |
$1,234.01
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Professional
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$161.50 |
| Rate for Payer: Aetna Commercial |
$161.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$161.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$85.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$154.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.50
|
| Rate for Payer: Quartz Beloit One Network |
$74.80
|
| Rate for Payer: Quartz Commercial |
$96.90
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$45.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$50.73
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Facility
IP
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.30 |
| Max. Negotiated Rate |
$156.40 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$102.00
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$102.00
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Facility
OP
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Aetna Commercial |
$153.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$146.20
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$90.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$156.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$151.30
|
| Rate for Payer: HFN Commercial |
$156.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$136.00
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$156.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$83.30
|
| Rate for Payer: Quartz Commercial |
$110.50
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$680.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$127.50
|
| Rate for Payer: WEA Trust Commercial |
$93.50
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$125.92
|
|
|
Tissue Transglutaminase Antibody IgA
|
Professional
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna Commercial |
$378.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$378.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$199.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$362.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: Preferred Network Access Commercial |
$378.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.12
|
| Rate for Payer: Quartz Commercial |
$226.86
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$45.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$50.73
|
|
|
Tissue Transglutaminase Antibody IgA
|
Facility
OP
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$1,592.00 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$258.70
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$1,592.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$298.50
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Tissue Transglutaminase Antibody IgA
|
Facility
IP
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$195.02 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$238.80
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Tissue Transglutaminase IgA Antibody
|
Facility
IP
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$86.73 |
| Max. Negotiated Rate |
$162.84 |
| Rate for Payer: Aetna Commercial |
$159.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.81
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$162.84
|
| Rate for Payer: Health EOS Commercial |
$157.53
|
| Rate for Payer: HFN Commercial |
$162.84
|
| Rate for Payer: Multiplan Commercial |
$141.60
|
| Rate for Payer: NAPHCARE Commercial |
$106.20
|
| Rate for Payer: Preferred Network Access Commercial |
$162.84
|
| Rate for Payer: Quartz Beloit One Network |
$86.73
|
| Rate for Payer: Quartz Commercial |
$106.20
|
| Rate for Payer: WEA Trust Commercial |
$97.35
|
| Rate for Payer: WPS Commercial |
$131.10
|
|
|
Tissue Transglutaminase IgA Antibody
|
Professional
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$168.15 |
| Rate for Payer: Aetna Commercial |
$168.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.22
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$168.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$161.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$141.60
|
| Rate for Payer: Preferred Network Access Commercial |
$168.15
|
| Rate for Payer: Quartz Beloit One Network |
$77.88
|
| Rate for Payer: Quartz Commercial |
$100.89
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$45.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: WEA Trust Commercial |
$97.35
|
| Rate for Payer: WPS Commercial |
$50.73
|
|
|
Tissue Transglutaminase IgA Antibody
|
Facility
OP
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$708.00 |
| Rate for Payer: Aetna Commercial |
$159.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.22
|
| Rate for Payer: Aetna Managed Medicare |
$11.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.18
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$11.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.53
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$162.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicaid |
$11.91
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.53
|
| Rate for Payer: Health EOS Commercial |
$157.53
|
| Rate for Payer: HFN Commercial |
$162.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.53
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.53
|
| Rate for Payer: Managed Health Services Medicaid |
$12.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.53
|
| Rate for Payer: Multiplan Commercial |
$141.60
|
| Rate for Payer: NAPHCARE Commercial |
$17.30
|
| Rate for Payer: Preferred Network Access Commercial |
$162.84
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.91
|
| Rate for Payer: Quartz Beloit One Network |
$86.73
|
| Rate for Payer: Quartz Commercial |
$115.05
|
| Rate for Payer: Quartz Medicare Advantage |
$11.53
|
| Rate for Payer: The Alliance Commercial |
$708.00
|
| Rate for Payer: United Healthcare Medicaid |
$11.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.53
|
| Rate for Payer: United Healthcare PPO |
$132.75
|
| Rate for Payer: WEA Trust Commercial |
$97.35
|
| Rate for Payer: Wellcare Medicare |
$11.53
|
| Rate for Payer: WMAP Medicaid |
$11.91
|
| Rate for Payer: WPS Commercial |
$131.10
|
|
|
TIS-U-TRAP 3MM FLEXIBLE
|
Facility
OP
|
$416.00
|
|
| Hospital Charge Code |
2969811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.48 |
| Max. Negotiated Rate |
$1,664.00 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$357.76
|
| Rate for Payer: Aetna Managed Medicare |
$116.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$270.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$199.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$232.79
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.00
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$270.40
|
| Rate for Payer: Quartz Medicare Advantage |
$249.60
|
| Rate for Payer: The Alliance Commercial |
$1,664.00
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.13
|
|
|
TIS-U-TRAP 3MM FLEXIBLE
|
Facility
IP
|
$416.00
|
|
| Hospital Charge Code |
2969811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.84 |
| Max. Negotiated Rate |
$382.72 |
| Rate for Payer: Aetna Commercial |
$374.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$220.48
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$382.72
|
| Rate for Payer: Health EOS Commercial |
$370.24
|
| Rate for Payer: HFN Commercial |
$382.72
|
| Rate for Payer: Multiplan Commercial |
$332.80
|
| Rate for Payer: NAPHCARE Commercial |
$249.60
|
| Rate for Payer: Preferred Network Access Commercial |
$382.72
|
| Rate for Payer: Quartz Beloit One Network |
$203.84
|
| Rate for Payer: Quartz Commercial |
$249.60
|
| Rate for Payer: WEA Trust Commercial |
$228.80
|
| Rate for Payer: WPS Commercial |
$308.13
|
|
|
Tobramycin
|
Facility
IP
|
$83.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
4075401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Tobramycin
|
Facility
OP
|
$83.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
4075401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$17,637.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$23.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.38
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.25
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$49.80
|
| Rate for Payer: The Alliance Commercial |
$17,637.36
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$6.38
|
|
|
Tobramycin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
IP
|
$650.00
|
|
| Hospital Charge Code |
2974989
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$318.50 |
| Max. Negotiated Rate |
$598.00 |
| Rate for Payer: Aetna Commercial |
$585.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$344.50
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$598.00
|
| Rate for Payer: Health EOS Commercial |
$578.50
|
| Rate for Payer: HFN Commercial |
$598.00
|
| Rate for Payer: Multiplan Commercial |
$520.00
|
| Rate for Payer: NAPHCARE Commercial |
$390.00
|
| Rate for Payer: Preferred Network Access Commercial |
$598.00
|
| Rate for Payer: Quartz Beloit One Network |
$318.50
|
| Rate for Payer: Quartz Commercial |
$390.00
|
| Rate for Payer: WEA Trust Commercial |
$357.50
|
| Rate for Payer: WPS Commercial |
$481.46
|
|
|
Tobramycin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
OP
|
$650.00
|
|
| Hospital Charge Code |
2974989
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$2,600.00 |
| Rate for Payer: Aetna Commercial |
$585.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$559.00
|
| Rate for Payer: Aetna Managed Medicare |
$182.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$422.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$325.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$344.50
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$598.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$363.74
|
| Rate for Payer: Health EOS Commercial |
$578.50
|
| Rate for Payer: HFN Commercial |
$598.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$487.50
|
| Rate for Payer: Multiplan Commercial |
$520.00
|
| Rate for Payer: NAPHCARE Commercial |
$390.00
|
| Rate for Payer: Preferred Network Access Commercial |
$598.00
|
| Rate for Payer: Quartz Beloit One Network |
$318.50
|
| Rate for Payer: Quartz Commercial |
$422.50
|
| Rate for Payer: Quartz Medicare Advantage |
$390.00
|
| Rate for Payer: The Alliance Commercial |
$2,600.00
|
| Rate for Payer: WEA Trust Commercial |
$357.50
|
| Rate for Payer: WPS Commercial |
$481.46
|
|
|
Tobramycin 0.3% Ophth Solution 5ml [Med]
|
Facility
OP
|
$28.00
|
|
| Hospital Charge Code |
2974990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Aetna Managed Medicare |
$7.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.67
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$18.20
|
| Rate for Payer: Quartz Medicare Advantage |
$16.80
|
| Rate for Payer: The Alliance Commercial |
$112.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Tobramycin 0.3% Ophth Solution 5ml [Med]
|
Facility
IP
|
$28.00
|
|
| Hospital Charge Code |
2974990
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$25.76 |
| Rate for Payer: Aetna Commercial |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.84
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$25.76
|
| Rate for Payer: Health EOS Commercial |
$24.92
|
| Rate for Payer: HFN Commercial |
$25.76
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: NAPHCARE Commercial |
$16.80
|
| Rate for Payer: Preferred Network Access Commercial |
$25.76
|
| Rate for Payer: Quartz Beloit One Network |
$13.72
|
| Rate for Payer: Quartz Commercial |
$16.80
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
