|
TISSUE EXPANDER 275CC 354211
|
Facility
|
IP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
2965394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.35 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$5,710.22
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 275CC 354211
|
Facility
|
OP
|
$9,151.00
|
|
|
Service Code
|
HCPCS L8600
|
| Hospital Charge Code |
2965394
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,664.77 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,664.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,186.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,758.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,568.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,325.88
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,137.78
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: NAPHCARE Commercial |
$5,710.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$6,186.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,710.22
|
| Rate for Payer: The Alliance Commercial |
$4,240.29
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 400CC 133MV13
|
Facility
|
OP
|
$8,512.00
|
|
| Hospital Charge Code |
2964627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.69 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,754.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,426.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,249.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.98
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,639.36
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: NAPHCARE Commercial |
$5,311.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,754.11
|
| Rate for Payer: Quartz Medicare Advantage |
$5,311.49
|
| Rate for Payer: The Alliance Commercial |
$4,426.24
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER 400CC 133MV13
|
Facility
|
IP
|
$8,512.00
|
|
| Hospital Charge Code |
2964627
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.72 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,311.49
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER 450CC 354213
|
Facility
|
IP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.35 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$5,710.22
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER 450CC 354213
|
Facility
|
OP
|
$9,151.00
|
|
| Hospital Charge Code |
2965396
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,664.77 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,664.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,186.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,758.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,568.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,325.88
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,137.78
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: NAPHCARE Commercial |
$5,710.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$6,186.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,710.22
|
| Rate for Payer: The Alliance Commercial |
$4,758.52
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER NATRELLE STYLE 133V 450CC 133FX-12
|
Facility
|
IP
|
$8,512.00
|
|
| Hospital Charge Code |
2964628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,337.72 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,311.49
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER NATRELLE STYLE 133V 450CC 133FX-12
|
Facility
|
OP
|
$8,512.00
|
|
| Hospital Charge Code |
2964628
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,478.69 |
| Max. Negotiated Rate |
$8,144.28 |
| Rate for Payer: Aetna Commercial |
$7,967.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,613.13
|
| Rate for Payer: Aetna Managed Medicare |
$2,478.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,754.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,426.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,249.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,691.81
|
| Rate for Payer: Cash Price |
$2,553.60
|
| Rate for Payer: Cigna Commercial |
$8,144.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,953.98
|
| Rate for Payer: Health EOS Commercial |
$7,878.71
|
| Rate for Payer: HFN Commercial |
$8,144.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,639.36
|
| Rate for Payer: Multiplan Commercial |
$7,081.98
|
| Rate for Payer: NAPHCARE Commercial |
$5,311.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8,144.28
|
| Rate for Payer: Quartz Beloit One Network |
$4,337.72
|
| Rate for Payer: Quartz Commercial |
$5,754.11
|
| Rate for Payer: Quartz Medicare Advantage |
$5,311.49
|
| Rate for Payer: The Alliance Commercial |
$4,426.24
|
| Rate for Payer: WEA Trust Commercial |
$4,868.86
|
| Rate for Payer: WPS Commercial |
$6,556.79
|
|
|
TISSUE EXPANDER TISSUE 350CC 354212
|
Facility
|
IP
|
$9,151.00
|
|
| Hospital Charge Code |
2965395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.35 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$5,710.22
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE EXPANDER TISSUE 350CC 354212
|
Facility
|
OP
|
$9,151.00
|
|
| Hospital Charge Code |
2965395
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,664.77 |
| Max. Negotiated Rate |
$8,755.68 |
| Rate for Payer: Aetna Commercial |
$8,565.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,184.65
|
| Rate for Payer: Aetna Managed Medicare |
$2,664.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,186.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,758.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,568.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,044.03
|
| Rate for Payer: Cash Price |
$2,745.30
|
| Rate for Payer: Cigna Commercial |
$8,755.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,325.88
|
| Rate for Payer: Health EOS Commercial |
$8,470.17
|
| Rate for Payer: HFN Commercial |
$8,755.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,137.78
|
| Rate for Payer: Multiplan Commercial |
$7,613.63
|
| Rate for Payer: NAPHCARE Commercial |
$5,710.22
|
| Rate for Payer: Preferred Network Access Commercial |
$8,755.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,663.35
|
| Rate for Payer: Quartz Commercial |
$6,186.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5,710.22
|
| Rate for Payer: The Alliance Commercial |
$4,758.52
|
| Rate for Payer: WEA Trust Commercial |
$5,234.37
|
| Rate for Payer: WPS Commercial |
$7,049.02
|
|
|
TISSUE MARKER ULTRA CLIP #861017
|
Facility
|
IP
|
$1,666.00
|
|
| Hospital Charge Code |
2973592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$848.99 |
| Max. Negotiated Rate |
$1,594.03 |
| Rate for Payer: Aetna Commercial |
$1,559.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,490.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$918.30
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,594.03
|
| Rate for Payer: Health EOS Commercial |
$1,542.05
|
| Rate for Payer: HFN Commercial |
$1,594.03
|
| Rate for Payer: Multiplan Commercial |
$1,386.11
|
| Rate for Payer: Preferred Network Access Commercial |
$1,594.03
|
| Rate for Payer: Quartz Beloit One Network |
$848.99
|
| Rate for Payer: Quartz Commercial |
$1,039.58
|
| Rate for Payer: WEA Trust Commercial |
$952.95
|
| Rate for Payer: WPS Commercial |
$1,283.32
|
|
|
TISSUE MARKER ULTRA CLIP #861017
|
Facility
|
OP
|
$1,666.00
|
|
| Hospital Charge Code |
2973592
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$485.14 |
| Max. Negotiated Rate |
$1,594.03 |
| Rate for Payer: Aetna Commercial |
$1,559.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,490.07
|
| Rate for Payer: Aetna Managed Medicare |
$485.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,126.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$866.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$831.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$918.30
|
| Rate for Payer: Cash Price |
$499.80
|
| Rate for Payer: Cigna Commercial |
$1,594.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$969.61
|
| Rate for Payer: Health EOS Commercial |
$1,542.05
|
| Rate for Payer: HFN Commercial |
$1,594.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,299.48
|
| Rate for Payer: Multiplan Commercial |
$1,386.11
|
| Rate for Payer: NAPHCARE Commercial |
$1,039.58
|
| Rate for Payer: Preferred Network Access Commercial |
$1,594.03
|
| Rate for Payer: Quartz Beloit One Network |
$848.99
|
| Rate for Payer: Quartz Commercial |
$1,126.22
|
| Rate for Payer: Quartz Medicare Advantage |
$1,039.58
|
| Rate for Payer: The Alliance Commercial |
$866.32
|
| Rate for Payer: WEA Trust Commercial |
$952.95
|
| Rate for Payer: WPS Commercial |
$1,283.32
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Professional
|
Both
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$167.96 |
| Rate for Payer: Aetna Commercial |
$167.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$167.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$160.89
|
| Rate for Payer: HFN Commercial |
$167.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$167.96
|
| Rate for Payer: Quartz Beloit One Network |
$77.79
|
| Rate for Payer: Quartz Commercial |
$100.78
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$52.76
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Facility
|
IP
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$86.63 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$106.08
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
Tissue Transglutaminase Antibodies IgG & IgA
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
983426
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$162.66 |
| Rate for Payer: Aetna Commercial |
$159.12
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$152.05
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cash Price |
$51.00
|
| Rate for Payer: Cigna Commercial |
$162.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$157.35
|
| Rate for Payer: HFN Commercial |
$162.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$141.44
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$162.66
|
| Rate for Payer: Quartz Beloit One Network |
$86.63
|
| Rate for Payer: Quartz Commercial |
$114.92
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: United Healthcare PPO |
$132.60
|
| Rate for Payer: WEA Trust Commercial |
$97.24
|
| Rate for Payer: Wellcare Medicare |
$11.99
|
| Rate for Payer: WPS Commercial |
$130.95
|
|
|
Tissue Transglutaminase Antibody IgA
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$393.22 |
| Rate for Payer: Aetna Commercial |
$393.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$393.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$376.67
|
| Rate for Payer: HFN Commercial |
$393.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$393.22
|
| Rate for Payer: Quartz Beloit One Network |
$182.12
|
| Rate for Payer: Quartz Commercial |
$235.93
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$52.76
|
|
|
Tissue Transglutaminase Antibody IgA
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.82 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$248.35
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Tissue Transglutaminase Antibody IgA
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
978078
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$269.05
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: United Healthcare PPO |
$310.44
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: Wellcare Medicare |
$11.99
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Tissue Transglutaminase IgA Antibody
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$169.35 |
| Rate for Payer: Aetna Commercial |
$165.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.31
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$169.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$103.01
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$163.83
|
| Rate for Payer: HFN Commercial |
$169.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$147.26
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$169.35
|
| Rate for Payer: Quartz Beloit One Network |
$90.20
|
| Rate for Payer: Quartz Commercial |
$119.65
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: United Healthcare PPO |
$138.06
|
| Rate for Payer: WEA Trust Commercial |
$101.24
|
| Rate for Payer: Wellcare Medicare |
$11.99
|
| Rate for Payer: WPS Commercial |
$136.34
|
|
|
Tissue Transglutaminase IgA Antibody
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$90.20 |
| Max. Negotiated Rate |
$169.35 |
| Rate for Payer: Aetna Commercial |
$165.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$97.56
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$169.35
|
| Rate for Payer: Health EOS Commercial |
$163.83
|
| Rate for Payer: HFN Commercial |
$169.35
|
| Rate for Payer: Multiplan Commercial |
$147.26
|
| Rate for Payer: Preferred Network Access Commercial |
$169.35
|
| Rate for Payer: Quartz Beloit One Network |
$90.20
|
| Rate for Payer: Quartz Commercial |
$110.45
|
| Rate for Payer: WEA Trust Commercial |
$101.24
|
| Rate for Payer: WPS Commercial |
$136.34
|
|
|
Tissue Transglutaminase IgA Antibody
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
2943017
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$174.88 |
| Rate for Payer: Aetna Commercial |
$174.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$158.31
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cash Price |
$53.10
|
| Rate for Payer: Cigna Commercial |
$174.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$92.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$167.51
|
| Rate for Payer: HFN Commercial |
$174.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$147.26
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$174.88
|
| Rate for Payer: Quartz Beloit One Network |
$81.00
|
| Rate for Payer: Quartz Commercial |
$104.93
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: WEA Trust Commercial |
$101.24
|
| Rate for Payer: WPS Commercial |
$52.76
|
|
|
TIS-U-TRAP 3MM FLEXIBLE
|
Facility
|
OP
|
$416.00
|
|
| Hospital Charge Code |
2969811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.14 |
| Max. Negotiated Rate |
$398.03 |
| Rate for Payer: Aetna Commercial |
$389.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$372.07
|
| Rate for Payer: Aetna Managed Medicare |
$121.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$281.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$216.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$207.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$229.30
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$398.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$242.11
|
| Rate for Payer: Health EOS Commercial |
$385.05
|
| Rate for Payer: HFN Commercial |
$398.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$324.48
|
| Rate for Payer: Multiplan Commercial |
$346.11
|
| Rate for Payer: NAPHCARE Commercial |
$259.58
|
| Rate for Payer: Preferred Network Access Commercial |
$398.03
|
| Rate for Payer: Quartz Beloit One Network |
$211.99
|
| Rate for Payer: Quartz Commercial |
$281.22
|
| Rate for Payer: Quartz Medicare Advantage |
$259.58
|
| Rate for Payer: The Alliance Commercial |
$216.32
|
| Rate for Payer: WEA Trust Commercial |
$237.95
|
| Rate for Payer: WPS Commercial |
$320.44
|
|
|
TIS-U-TRAP 3MM FLEXIBLE
|
Facility
|
IP
|
$416.00
|
|
| Hospital Charge Code |
2969811
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$211.99 |
| Max. Negotiated Rate |
$398.03 |
| Rate for Payer: Aetna Commercial |
$389.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$372.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$229.30
|
| Rate for Payer: Cash Price |
$124.80
|
| Rate for Payer: Cigna Commercial |
$398.03
|
| Rate for Payer: Health EOS Commercial |
$385.05
|
| Rate for Payer: HFN Commercial |
$398.03
|
| Rate for Payer: Multiplan Commercial |
$346.11
|
| Rate for Payer: Preferred Network Access Commercial |
$398.03
|
| Rate for Payer: Quartz Beloit One Network |
$211.99
|
| Rate for Payer: Quartz Commercial |
$259.58
|
| Rate for Payer: WEA Trust Commercial |
$237.95
|
| Rate for Payer: WPS Commercial |
$320.44
|
|
|
Tobramycin
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
4075401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.51 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$24.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.51
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.74
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$51.79
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$56.11
|
| Rate for Payer: Quartz Medicare Advantage |
$51.79
|
| Rate for Payer: The Alliance Commercial |
$8.61
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$6.64
|
|
|
Tobramycin
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
4075401
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
