|
U24 5 HIAA / 523
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
977767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$190.61 |
| Max. Negotiated Rate |
$357.88 |
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.40
|
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$233.40
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
U24 5 HIAA / 523
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
CPT 83497
|
| Hospital Charge Code |
977767
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$45.54 |
| Max. Negotiated Rate |
$369.55 |
| Rate for Payer: Aetna Commercial |
$369.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$369.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$194.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.40
|
| Rate for Payer: Health EOS Commercial |
$353.99
|
| Rate for Payer: HFN Commercial |
$369.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.54
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.55
|
| Rate for Payer: Quartz Beloit One Network |
$171.16
|
| Rate for Payer: Quartz Commercial |
$221.73
|
| Rate for Payer: The Alliance Commercial |
$194.50
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
U24 Creat
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
4619170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
U24 Creat
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
4619170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$20.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.54
|
| Rate for Payer: Anthem Medicaid |
$21.50
|
| Rate for Payer: Anthem Medicare Advantage |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.81
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Dean Health Medicaid |
$21.50
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.81
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.81
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.81
|
| Rate for Payer: Managed Health Services Medicaid |
$22.36
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.81
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$31.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.50
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$20.81
|
| Rate for Payer: The Alliance Commercial |
$83.24
|
| Rate for Payer: United Healthcare Medicaid |
$21.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.81
|
| Rate for Payer: United Healthcare PPO |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: Wellcare Medicare |
$20.81
|
| Rate for Payer: WMAP Medicaid |
$21.50
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
U24 Creat
|
Professional
|
Both
|
$4.00
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
4619170
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1.76 |
| Max. Negotiated Rate |
$73.46 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.40
|
| Rate for Payer: Health EOS Commercial |
$3.64
|
| Rate for Payer: HFN Commercial |
$3.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.46
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3.80
|
| Rate for Payer: Quartz Beloit One Network |
$1.76
|
| Rate for Payer: Quartz Commercial |
$2.28
|
| Rate for Payer: The Alliance Commercial |
$2.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
U24 Creatinine
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
978113
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$110.20 |
| Rate for Payer: Aetna Commercial |
$110.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$110.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$58.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.60
|
| Rate for Payer: Health EOS Commercial |
$105.56
|
| Rate for Payer: HFN Commercial |
$110.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: Preferred Network Access Commercial |
$110.20
|
| Rate for Payer: Quartz Beloit One Network |
$51.04
|
| Rate for Payer: Quartz Commercial |
$66.12
|
| Rate for Payer: The Alliance Commercial |
$58.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
U24 Creatinine
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
978113
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$106.72 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Aetna Managed Medicare |
$5.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.60
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem Medicare Advantage |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.18
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$106.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.91
|
| Rate for Payer: Dean Health Medicaid |
$5.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.18
|
| Rate for Payer: Health EOS Commercial |
$103.24
|
| Rate for Payer: HFN Commercial |
$106.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.18
|
| Rate for Payer: Managed Health Services Medicaid |
$5.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$7.77
|
| Rate for Payer: Preferred Network Access Commercial |
$106.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.35
|
| Rate for Payer: Quartz Beloit One Network |
$56.84
|
| Rate for Payer: Quartz Commercial |
$75.40
|
| Rate for Payer: Quartz Medicare Advantage |
$5.18
|
| Rate for Payer: The Alliance Commercial |
$20.72
|
| Rate for Payer: United Healthcare Medicaid |
$5.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: United Healthcare PPO |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: Wellcare Medicare |
$5.18
|
| Rate for Payer: WMAP Medicaid |
$5.35
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
U24 Creatinine
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
978113
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.84 |
| Max. Negotiated Rate |
$106.72 |
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$69.60
|
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$61.48
|
| Rate for Payer: Cash Price |
$34.80
|
| Rate for Payer: Cigna Commercial |
$106.72
|
| Rate for Payer: Health EOS Commercial |
$103.24
|
| Rate for Payer: HFN Commercial |
$106.72
|
| Rate for Payer: Preferred Network Access Commercial |
$106.72
|
| Rate for Payer: Quartz Beloit One Network |
$56.84
|
| Rate for Payer: Quartz Commercial |
$69.60
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
U24 Heavy Metal / 35386
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.92 |
| Max. Negotiated Rate |
$579.50 |
| Rate for Payer: Aetna Commercial |
$579.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$579.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$305.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$366.00
|
| Rate for Payer: Health EOS Commercial |
$555.10
|
| Rate for Payer: HFN Commercial |
$579.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$73.92
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: Preferred Network Access Commercial |
$579.50
|
| Rate for Payer: Quartz Beloit One Network |
$268.40
|
| Rate for Payer: Quartz Commercial |
$347.70
|
| Rate for Payer: The Alliance Commercial |
$305.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
U24 Heavy Metal / 35386
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.94 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Aetna Managed Medicare |
$20.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.76
|
| Rate for Payer: Anthem Medicaid |
$21.64
|
| Rate for Payer: Anthem Medicare Advantage |
$20.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.94
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$341.36
|
| Rate for Payer: Dean Health Medicaid |
$21.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.94
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$77.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.94
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.94
|
| Rate for Payer: Managed Health Services Medicaid |
$22.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.94
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$31.41
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$21.64
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$396.50
|
| Rate for Payer: Quartz Medicare Advantage |
$20.94
|
| Rate for Payer: The Alliance Commercial |
$83.76
|
| Rate for Payer: United Healthcare Medicaid |
$21.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.94
|
| Rate for Payer: United Healthcare PPO |
$457.50
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: Wellcare Medicare |
$20.94
|
| Rate for Payer: WMAP Medicaid |
$21.64
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
U24 Heavy Metal / 35386
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
CPT 83015
|
| Hospital Charge Code |
977961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$298.90 |
| Max. Negotiated Rate |
$561.20 |
| Rate for Payer: Aetna Commercial |
$549.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$524.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$323.30
|
| Rate for Payer: Cash Price |
$183.00
|
| Rate for Payer: Cigna Commercial |
$561.20
|
| Rate for Payer: Health EOS Commercial |
$542.90
|
| Rate for Payer: HFN Commercial |
$561.20
|
| Rate for Payer: Multiplan Commercial |
$488.00
|
| Rate for Payer: NAPHCARE Commercial |
$366.00
|
| Rate for Payer: Preferred Network Access Commercial |
$561.20
|
| Rate for Payer: Quartz Beloit One Network |
$298.90
|
| Rate for Payer: Quartz Commercial |
$366.00
|
| Rate for Payer: WEA Trust Commercial |
$335.50
|
| Rate for Payer: WPS Commercial |
$451.83
|
|
|
U24 Porphyrins, Fract, Qnt / 729
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
983365
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$568.56 |
| Rate for Payer: Aetna Commercial |
$556.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$531.48
|
| Rate for Payer: Aetna Managed Medicare |
$14.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$15.20
|
| Rate for Payer: Anthem Medicare Advantage |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$327.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.71
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$568.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$345.83
|
| Rate for Payer: Dean Health Medicaid |
$15.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.71
|
| Rate for Payer: Health EOS Commercial |
$550.02
|
| Rate for Payer: HFN Commercial |
$568.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.71
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.71
|
| Rate for Payer: Managed Health Services Medicaid |
$15.81
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$494.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.06
|
| Rate for Payer: Preferred Network Access Commercial |
$568.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.20
|
| Rate for Payer: Quartz Beloit One Network |
$302.82
|
| Rate for Payer: Quartz Commercial |
$401.70
|
| Rate for Payer: Quartz Medicare Advantage |
$14.71
|
| Rate for Payer: The Alliance Commercial |
$58.84
|
| Rate for Payer: United Healthcare Medicaid |
$15.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.71
|
| Rate for Payer: United Healthcare PPO |
$463.50
|
| Rate for Payer: WEA Trust Commercial |
$339.90
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
| Rate for Payer: WMAP Medicaid |
$15.20
|
| Rate for Payer: WPS Commercial |
$457.75
|
|
|
U24 Porphyrins, Fract, Qnt / 729
|
Professional
|
Both
|
$618.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
983365
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.93 |
| Max. Negotiated Rate |
$587.10 |
| Rate for Payer: Aetna Commercial |
$587.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$531.48
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$587.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$309.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$370.80
|
| Rate for Payer: Health EOS Commercial |
$562.38
|
| Rate for Payer: HFN Commercial |
$587.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.93
|
| Rate for Payer: Multiplan Commercial |
$494.40
|
| Rate for Payer: Preferred Network Access Commercial |
$587.10
|
| Rate for Payer: Quartz Beloit One Network |
$271.92
|
| Rate for Payer: Quartz Commercial |
$352.26
|
| Rate for Payer: The Alliance Commercial |
$309.00
|
| Rate for Payer: WEA Trust Commercial |
$339.90
|
| Rate for Payer: WPS Commercial |
$457.75
|
|
|
U24 Porphyrins, Fract, Qnt / 729
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
CPT 84120
|
| Hospital Charge Code |
983365
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$302.82 |
| Max. Negotiated Rate |
$568.56 |
| Rate for Payer: Aetna Commercial |
$556.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$531.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$327.54
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$568.56
|
| Rate for Payer: Health EOS Commercial |
$550.02
|
| Rate for Payer: HFN Commercial |
$568.56
|
| Rate for Payer: Multiplan Commercial |
$494.40
|
| Rate for Payer: NAPHCARE Commercial |
$370.80
|
| Rate for Payer: Preferred Network Access Commercial |
$568.56
|
| Rate for Payer: Quartz Beloit One Network |
$302.82
|
| Rate for Payer: Quartz Commercial |
$370.80
|
| Rate for Payer: WEA Trust Commercial |
$339.90
|
| Rate for Payer: WPS Commercial |
$457.75
|
|
|
U Arsenic / 270
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
977872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.77 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$103.80
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$103.80
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
U Arsenic / 270
|
Professional
|
Both
|
$173.00
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
977872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.96 |
| Max. Negotiated Rate |
$164.35 |
| Rate for Payer: Aetna Commercial |
$164.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$164.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$86.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.80
|
| Rate for Payer: Health EOS Commercial |
$157.43
|
| Rate for Payer: HFN Commercial |
$164.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.96
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: Preferred Network Access Commercial |
$164.35
|
| Rate for Payer: Quartz Beloit One Network |
$76.12
|
| Rate for Payer: Quartz Commercial |
$98.61
|
| Rate for Payer: The Alliance Commercial |
$86.50
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
U Arsenic / 270
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 82175
|
| Hospital Charge Code |
977872
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.97 |
| Max. Negotiated Rate |
$159.16 |
| Rate for Payer: Aetna Commercial |
$155.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.78
|
| Rate for Payer: Aetna Managed Medicare |
$18.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.49
|
| Rate for Payer: Anthem Medicaid |
$19.60
|
| Rate for Payer: Anthem Medicare Advantage |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.97
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cash Price |
$51.90
|
| Rate for Payer: Cigna Commercial |
$159.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.81
|
| Rate for Payer: Dean Health Medicaid |
$19.60
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.97
|
| Rate for Payer: Health EOS Commercial |
$153.97
|
| Rate for Payer: HFN Commercial |
$159.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.60
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.97
|
| Rate for Payer: Managed Health Services Medicaid |
$20.38
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.97
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.97
|
| Rate for Payer: Multiplan Commercial |
$138.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.46
|
| Rate for Payer: Preferred Network Access Commercial |
$159.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.60
|
| Rate for Payer: Quartz Beloit One Network |
$84.77
|
| Rate for Payer: Quartz Commercial |
$112.45
|
| Rate for Payer: Quartz Medicare Advantage |
$18.97
|
| Rate for Payer: The Alliance Commercial |
$75.88
|
| Rate for Payer: United Healthcare Medicaid |
$19.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.97
|
| Rate for Payer: United Healthcare PPO |
$129.75
|
| Rate for Payer: WEA Trust Commercial |
$95.15
|
| Rate for Payer: Wellcare Medicare |
$18.97
|
| Rate for Payer: WMAP Medicaid |
$19.60
|
| Rate for Payer: WPS Commercial |
$128.14
|
|
|
U Creatinine
|
Professional
|
Both
|
$19.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4506665
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$18.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$18.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.40
|
| Rate for Payer: Health EOS Commercial |
$17.29
|
| Rate for Payer: HFN Commercial |
$18.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: Preferred Network Access Commercial |
$18.05
|
| Rate for Payer: Quartz Beloit One Network |
$8.36
|
| Rate for Payer: Quartz Commercial |
$10.83
|
| Rate for Payer: The Alliance Commercial |
$9.50
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
U Creatinine
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4506665
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$17.48 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$11.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$11.40
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
U Creatinine
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
4506665
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$20.72 |
| Rate for Payer: Aetna Commercial |
$17.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.34
|
| Rate for Payer: Aetna Managed Medicare |
$5.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.06
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.60
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem Medicare Advantage |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.18
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cash Price |
$5.70
|
| Rate for Payer: Cigna Commercial |
$17.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.63
|
| Rate for Payer: Dean Health Medicaid |
$5.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.18
|
| Rate for Payer: Health EOS Commercial |
$16.91
|
| Rate for Payer: HFN Commercial |
$17.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.18
|
| Rate for Payer: Managed Health Services Medicaid |
$5.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.18
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.18
|
| Rate for Payer: Multiplan Commercial |
$15.20
|
| Rate for Payer: NAPHCARE Commercial |
$7.77
|
| Rate for Payer: Preferred Network Access Commercial |
$17.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.35
|
| Rate for Payer: Quartz Beloit One Network |
$9.31
|
| Rate for Payer: Quartz Commercial |
$12.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5.18
|
| Rate for Payer: The Alliance Commercial |
$20.72
|
| Rate for Payer: United Healthcare Medicaid |
$5.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.18
|
| Rate for Payer: United Healthcare PPO |
$14.25
|
| Rate for Payer: WEA Trust Commercial |
$10.45
|
| Rate for Payer: Wellcare Medicare |
$5.18
|
| Rate for Payer: WMAP Medicaid |
$5.35
|
| Rate for Payer: WPS Commercial |
$14.07
|
|
|
UE Fx Orth Shoul Cap Forearm L3981
|
Facility
|
OP
|
$1,326.00
|
|
|
Service Code
|
HCPCS L3981
|
| Hospital Charge Code |
4924611
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$371.28 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$1,193.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,140.36
|
| Rate for Payer: Aetna Managed Medicare |
$371.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$861.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$663.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$636.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.78
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cigna Commercial |
$1,219.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$742.03
|
| Rate for Payer: Health EOS Commercial |
$1,180.14
|
| Rate for Payer: HFN Commercial |
$1,219.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$994.50
|
| Rate for Payer: Multiplan Commercial |
$1,060.80
|
| Rate for Payer: NAPHCARE Commercial |
$795.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.92
|
| Rate for Payer: Quartz Beloit One Network |
$649.74
|
| Rate for Payer: Quartz Commercial |
$861.90
|
| Rate for Payer: Quartz Medicare Advantage |
$795.60
|
| Rate for Payer: The Alliance Commercial |
$5,304.00
|
| Rate for Payer: WEA Trust Commercial |
$729.30
|
| Rate for Payer: WPS Commercial |
$982.17
|
|
|
UE Fx Orth Shoul Cap Forearm L3981
|
Facility
|
IP
|
$1,326.00
|
|
|
Service Code
|
HCPCS L3981
|
| Hospital Charge Code |
4924611
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$649.74 |
| Max. Negotiated Rate |
$1,219.92 |
| Rate for Payer: Aetna Commercial |
$1,193.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,140.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$702.78
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cigna Commercial |
$1,219.92
|
| Rate for Payer: Health EOS Commercial |
$1,180.14
|
| Rate for Payer: HFN Commercial |
$1,219.92
|
| Rate for Payer: Multiplan Commercial |
$1,060.80
|
| Rate for Payer: NAPHCARE Commercial |
$795.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,219.92
|
| Rate for Payer: Quartz Beloit One Network |
$649.74
|
| Rate for Payer: Quartz Commercial |
$795.60
|
| Rate for Payer: WEA Trust Commercial |
$729.30
|
| Rate for Payer: WPS Commercial |
$982.17
|
|
|
UE Fx Orth Shoul Cap Forearm L3981
|
Professional
|
Both
|
$1,326.00
|
|
|
Service Code
|
HCPCS L3981
|
| Hospital Charge Code |
4924611
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$583.44 |
| Max. Negotiated Rate |
$3,246.08 |
| Rate for Payer: Aetna Commercial |
$1,259.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,140.36
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cash Price |
$397.80
|
| Rate for Payer: Cigna Commercial |
$1,259.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$663.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$795.60
|
| Rate for Payer: Health EOS Commercial |
$1,206.66
|
| Rate for Payer: HFN Commercial |
$1,259.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,246.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,246.08
|
| Rate for Payer: Multiplan Commercial |
$1,060.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,259.70
|
| Rate for Payer: Quartz Beloit One Network |
$583.44
|
| Rate for Payer: Quartz Commercial |
$755.82
|
| Rate for Payer: The Alliance Commercial |
$663.00
|
| Rate for Payer: WEA Trust Commercial |
$729.30
|
| Rate for Payer: WPS Commercial |
$982.17
|
|
|
U Ethyl Glucuronide / 90418
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 80321
|
| Hospital Charge Code |
3530179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.55 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$122.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.94
|
| 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 |
$77.40
|
| Rate for Payer: Health EOS Commercial |
$117.39
|
| Rate for Payer: HFN Commercial |
$122.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.55
|
| 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: The Alliance Commercial |
$64.50
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
|
U Ethyl Glucuronide / 90418
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 80321
|
| Hospital Charge Code |
3530179
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.12 |
| 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 |
$36.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.92
|
| 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: Dean Health DHI/DHP/ASO |
$72.19
|
| Rate for Payer: Health EOS Commercial |
$114.81
|
| Rate for Payer: HFN Commercial |
$118.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.75
|
| 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 |
$83.85
|
| Rate for Payer: Quartz Medicare Advantage |
$77.40
|
| Rate for Payer: The Alliance Commercial |
$516.00
|
| Rate for Payer: United Healthcare PPO |
$96.75
|
| Rate for Payer: WEA Trust Commercial |
$70.95
|
| Rate for Payer: WPS Commercial |
$95.55
|
|
