|
BCE XR US Guided Midline
|
Facility
OP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$124.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$124.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$816.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$689.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$655.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$333.75
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$289.25
|
| Rate for Payer: Quartz Medicare Advantage |
$267.00
|
| Rate for Payer: The Alliance Commercial |
$1,780.00
|
| Rate for Payer: United Healthcare PPO |
$574.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
BCE XR US Guided Midline
|
Professional
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$24.47 |
| Max. Negotiated Rate |
$422.75 |
| Rate for Payer: Aetna Commercial |
$422.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$382.70
|
| Rate for Payer: Aetna Managed Medicare |
$24.47
|
| Rate for Payer: Anthem Medicare Advantage |
$24.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.47
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$422.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$222.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.47
|
| Rate for Payer: Health EOS Commercial |
$404.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.47
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: Preferred Network Access Commercial |
$422.75
|
| Rate for Payer: Quartz Beloit One Network |
$195.80
|
| Rate for Payer: Quartz Commercial |
$253.65
|
| Rate for Payer: Quartz Medicare Advantage |
$24.47
|
| Rate for Payer: The Alliance Commercial |
$92.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.47
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$122.35
|
|
|
BCE XR US Guided Midline
|
Facility
IP
|
$445.00
|
|
|
Service Code
|
CPT 76937 TC
|
| Hospital Charge Code |
5552132
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$218.05 |
| Max. Negotiated Rate |
$409.40 |
| Rate for Payer: Aetna Commercial |
$400.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$235.85
|
| Rate for Payer: Cash Price |
$133.50
|
| Rate for Payer: Cigna Commercial |
$409.40
|
| Rate for Payer: Health EOS Commercial |
$396.05
|
| Rate for Payer: HFN Commercial |
$409.40
|
| Rate for Payer: Multiplan Commercial |
$356.00
|
| Rate for Payer: NAPHCARE Commercial |
$267.00
|
| Rate for Payer: Preferred Network Access Commercial |
$409.40
|
| Rate for Payer: Quartz Beloit One Network |
$218.05
|
| Rate for Payer: Quartz Commercial |
$267.00
|
| Rate for Payer: WEA Trust Commercial |
$244.75
|
| Rate for Payer: WPS Commercial |
$329.61
|
|
|
BCG 1 Unit Charge
|
Facility
IP
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$377.30 |
| Max. Negotiated Rate |
$708.40 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$408.10
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$708.40
|
| Rate for Payer: Health EOS Commercial |
$685.30
|
| Rate for Payer: HFN Commercial |
$708.40
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: NAPHCARE Commercial |
$462.00
|
| Rate for Payer: Preferred Network Access Commercial |
$708.40
|
| Rate for Payer: Quartz Beloit One Network |
$377.30
|
| Rate for Payer: Quartz Commercial |
$462.00
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$570.34
|
|
|
BCG 1 Unit Charge
|
Professional
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$731.50 |
| Rate for Payer: Aetna Commercial |
$731.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$662.20
|
| Rate for Payer: Aetna Managed Medicare |
$2.89
|
| Rate for Payer: Anthem Medicare Advantage |
$2.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.89
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$731.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$385.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.89
|
| Rate for Payer: Health EOS Commercial |
$700.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: Preferred Network Access Commercial |
$731.50
|
| Rate for Payer: Quartz Beloit One Network |
$338.80
|
| Rate for Payer: Quartz Commercial |
$438.90
|
| Rate for Payer: Quartz Medicare Advantage |
$2.89
|
| Rate for Payer: The Alliance Commercial |
$7.96
|
| Rate for Payer: United Healthcare Medicaid |
$2.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.89
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
BCG 1 Unit Charge
|
Facility
OP
|
$770.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
2958944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$1,571.88 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$662.20
|
| Rate for Payer: Aetna Managed Medicare |
$215.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$500.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$385.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$408.10
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cigna Commercial |
$708.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.82
|
| Rate for Payer: Health EOS Commercial |
$685.30
|
| Rate for Payer: HFN Commercial |
$708.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$577.50
|
| Rate for Payer: Multiplan Commercial |
$616.00
|
| Rate for Payer: NAPHCARE Commercial |
$462.00
|
| Rate for Payer: Preferred Network Access Commercial |
$708.40
|
| Rate for Payer: Quartz Beloit One Network |
$377.30
|
| Rate for Payer: Quartz Commercial |
$500.50
|
| Rate for Payer: Quartz Medicare Advantage |
$462.00
|
| Rate for Payer: The Alliance Commercial |
$1,571.88
|
| Rate for Payer: WEA Trust Commercial |
$423.50
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
Bcg live intravesical vac J9030
|
Facility
IP
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.32 |
| Max. Negotiated Rate |
$338.56 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$220.80
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$272.58
|
|
|
Bcg live intravesical vac J9030
|
Facility
OP
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.82 |
| Max. Negotiated Rate |
$1,571.88 |
| Rate for Payer: Aetna Commercial |
$331.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$103.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.04
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$338.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.82
|
| Rate for Payer: Health EOS Commercial |
$327.52
|
| Rate for Payer: HFN Commercial |
$338.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.00
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: NAPHCARE Commercial |
$220.80
|
| Rate for Payer: Preferred Network Access Commercial |
$338.56
|
| Rate for Payer: Quartz Beloit One Network |
$180.32
|
| Rate for Payer: Quartz Commercial |
$239.20
|
| Rate for Payer: Quartz Medicare Advantage |
$220.80
|
| Rate for Payer: The Alliance Commercial |
$1,571.88
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
Bcg live intravesical vac J9030
|
Professional
|
$368.00
|
|
|
Service Code
|
HCPCS J9030
|
| Hospital Charge Code |
5528774
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$349.60 |
| Rate for Payer: Aetna Commercial |
$349.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.48
|
| Rate for Payer: Aetna Managed Medicare |
$2.89
|
| Rate for Payer: Anthem Medicare Advantage |
$2.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.89
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cash Price |
$110.40
|
| Rate for Payer: Cigna Commercial |
$349.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.89
|
| Rate for Payer: Health EOS Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.89
|
| Rate for Payer: Multiplan Commercial |
$294.40
|
| Rate for Payer: Preferred Network Access Commercial |
$349.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.92
|
| Rate for Payer: Quartz Commercial |
$209.76
|
| Rate for Payer: Quartz Medicare Advantage |
$2.89
|
| Rate for Payer: The Alliance Commercial |
$7.96
|
| Rate for Payer: United Healthcare Medicaid |
$2.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.89
|
| Rate for Payer: WEA Trust Commercial |
$202.40
|
| Rate for Payer: WPS Commercial |
$7.22
|
|
|
BCR-ABL 1 / 91065
|
Professional
|
$190.00
|
|
|
Service Code
|
CPT 81206
|
| Hospital Charge Code |
5313604
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.60 |
| Max. Negotiated Rate |
$721.42 |
| Rate for Payer: Aetna Commercial |
$180.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$163.40
|
| Rate for Payer: Aetna Managed Medicare |
$163.96
|
| Rate for Payer: Anthem Medicare Advantage |
$163.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$163.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$163.96
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$180.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$163.96
|
| Rate for Payer: Health EOS Commercial |
$172.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$578.78
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$578.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$163.96
|
| Rate for Payer: Multiplan Commercial |
$152.00
|
| Rate for Payer: Preferred Network Access Commercial |
$180.50
|
| Rate for Payer: Quartz Beloit One Network |
$83.60
|
| Rate for Payer: Quartz Commercial |
$108.30
|
| Rate for Payer: Quartz Medicare Advantage |
$163.96
|
| Rate for Payer: The Alliance Commercial |
$647.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$163.96
|
| Rate for Payer: WEA Trust Commercial |
$104.50
|
| Rate for Payer: WPS Commercial |
$721.42
|
|
|
BCR-ABL 1 / 91065
|
Facility
OP
|
$190.00
|
|
|
Service Code
|
CPT 81206
|
| Hospital Charge Code |
5313604
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.10 |
| Max. Negotiated Rate |
$760.00 |
| Rate for Payer: Aetna Commercial |
$171.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$163.40
|
| Rate for Payer: Aetna Managed Medicare |
$163.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$614.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$286.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$272.17
|
| Rate for Payer: Anthem Medicaid |
$169.42
|
| Rate for Payer: Anthem Medicare Advantage |
$163.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$163.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$163.96
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$163.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$169.42
|
| Rate for Payer: Dean Health Medicaid |
$169.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$163.96
|
| Rate for Payer: Health EOS Commercial |
$169.10
|
| Rate for Payer: HFN Commercial |
$174.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$609.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$163.96
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$169.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$163.96
|
| Rate for Payer: Managed Health Services Medicaid |
$176.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$163.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$163.96
|
| Rate for Payer: Multiplan Commercial |
$152.00
|
| Rate for Payer: NAPHCARE Commercial |
$245.94
|
| Rate for Payer: Preferred Network Access Commercial |
$174.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$169.42
|
| Rate for Payer: Quartz Beloit One Network |
$93.10
|
| Rate for Payer: Quartz Commercial |
$123.50
|
| Rate for Payer: Quartz Medicare Advantage |
$163.96
|
| Rate for Payer: The Alliance Commercial |
$760.00
|
| Rate for Payer: United Healthcare Medicaid |
$169.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$163.96
|
| Rate for Payer: United Healthcare PPO |
$142.50
|
| Rate for Payer: WEA Trust Commercial |
$104.50
|
| Rate for Payer: Wellcare Medicare |
$163.96
|
| Rate for Payer: WMAP Medicaid |
$169.42
|
| Rate for Payer: WPS Commercial |
$140.73
|
|
|
BCR-ABL 1 / 91065
|
Facility
IP
|
$190.00
|
|
|
Service Code
|
CPT 81206
|
| Hospital Charge Code |
5313604
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.10 |
| Max. Negotiated Rate |
$174.80 |
| Rate for Payer: Aetna Commercial |
$171.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.70
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Health EOS Commercial |
$169.10
|
| Rate for Payer: HFN Commercial |
$174.80
|
| Rate for Payer: Multiplan Commercial |
$152.00
|
| Rate for Payer: NAPHCARE Commercial |
$114.00
|
| Rate for Payer: Preferred Network Access Commercial |
$174.80
|
| Rate for Payer: Quartz Beloit One Network |
$93.10
|
| Rate for Payer: Quartz Commercial |
$114.00
|
| Rate for Payer: WEA Trust Commercial |
$104.50
|
| Rate for Payer: WPS Commercial |
$140.73
|
|
|
BCR ABL1/ABL1%(IS)
|
Facility
IP
|
$237.00
|
|
|
Service Code
|
CPT 81207
|
| Hospital Charge Code |
5313656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$218.04 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$142.20
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$142.20
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
BCR ABL1/ABL1%(IS)
|
Professional
|
$237.00
|
|
|
Service Code
|
CPT 81207
|
| Hospital Charge Code |
5313656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.28 |
| Max. Negotiated Rate |
$637.30 |
| Rate for Payer: Aetna Commercial |
$225.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Aetna Managed Medicare |
$144.84
|
| Rate for Payer: Anthem Medicare Advantage |
$144.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$144.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$144.84
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$225.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.84
|
| Rate for Payer: Health EOS Commercial |
$215.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$511.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$511.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$144.84
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: Preferred Network Access Commercial |
$225.15
|
| Rate for Payer: Quartz Beloit One Network |
$104.28
|
| Rate for Payer: Quartz Commercial |
$135.09
|
| Rate for Payer: Quartz Medicare Advantage |
$144.84
|
| Rate for Payer: The Alliance Commercial |
$572.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$144.84
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: WPS Commercial |
$637.30
|
|
|
BCR ABL1/ABL1%(IS)
|
Facility
OP
|
$237.00
|
|
|
Service Code
|
CPT 81207
|
| Hospital Charge Code |
5313656
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.13 |
| Max. Negotiated Rate |
$948.00 |
| Rate for Payer: Aetna Commercial |
$213.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$203.82
|
| Rate for Payer: Aetna Managed Medicare |
$144.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$543.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$253.47
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.43
|
| Rate for Payer: Anthem Medicaid |
$149.66
|
| Rate for Payer: Anthem Medicare Advantage |
$144.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$125.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$144.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$144.84
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$218.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$144.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$149.66
|
| Rate for Payer: Dean Health Medicaid |
$149.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$144.84
|
| Rate for Payer: Health EOS Commercial |
$210.93
|
| Rate for Payer: HFN Commercial |
$218.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$538.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$144.84
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$149.66
|
| Rate for Payer: Independent Care Health Plan Medicare |
$144.84
|
| Rate for Payer: Managed Health Services Medicaid |
$155.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$144.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$144.84
|
| Rate for Payer: Multiplan Commercial |
$189.60
|
| Rate for Payer: NAPHCARE Commercial |
$217.26
|
| Rate for Payer: Preferred Network Access Commercial |
$218.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$149.66
|
| Rate for Payer: Quartz Beloit One Network |
$116.13
|
| Rate for Payer: Quartz Commercial |
$154.05
|
| Rate for Payer: Quartz Medicare Advantage |
$144.84
|
| Rate for Payer: The Alliance Commercial |
$948.00
|
| Rate for Payer: United Healthcare Medicaid |
$149.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$144.84
|
| Rate for Payer: United Healthcare PPO |
$177.75
|
| Rate for Payer: WEA Trust Commercial |
$130.35
|
| Rate for Payer: Wellcare Medicare |
$144.84
|
| Rate for Payer: WMAP Medicaid |
$149.66
|
| Rate for Payer: WPS Commercial |
$175.55
|
|
|
BCR/ABL Amplification
|
Facility
IP
|
$116.00
|
|
| Hospital Charge Code |
2788814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.84 |
| Max. Negotiated Rate |
$106.72 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| 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: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$69.60
|
| 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
|
|
|
BCR/ABL Amplification
|
Professional
|
$116.00
|
|
| Hospital Charge Code |
2788814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$51.04 |
| 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: 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: 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
|
|
|
BCR/ABL Amplification
|
Facility
OP
|
$116.00
|
|
| Hospital Charge Code |
2788814
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.48 |
| Max. Negotiated Rate |
$464.00 |
| Rate for Payer: Aetna Commercial |
$104.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$99.76
|
| Rate for Payer: Aetna Managed Medicare |
$32.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$75.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$58.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.68
|
| 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: Dean Health DHI/DHP/ASO |
$64.91
|
| Rate for Payer: Health EOS Commercial |
$103.24
|
| Rate for Payer: HFN Commercial |
$106.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.00
|
| Rate for Payer: Multiplan Commercial |
$92.80
|
| Rate for Payer: NAPHCARE Commercial |
$69.60
|
| Rate for Payer: Preferred Network Access Commercial |
$106.72
|
| Rate for Payer: Quartz Beloit One Network |
$56.84
|
| Rate for Payer: Quartz Commercial |
$75.40
|
| Rate for Payer: Quartz Medicare Advantage |
$69.60
|
| Rate for Payer: The Alliance Commercial |
$464.00
|
| Rate for Payer: United Healthcare PPO |
$87.00
|
| Rate for Payer: WEA Trust Commercial |
$63.80
|
| Rate for Payer: WPS Commercial |
$85.92
|
|
|
BCR/ABL Extraction
|
Professional
|
$46.00
|
|
| Hospital Charge Code |
2790799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.24 |
| Max. Negotiated Rate |
$43.70 |
| Rate for Payer: Aetna Commercial |
$43.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.56
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$43.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$41.86
|
| Rate for Payer: Multiplan Commercial |
$36.80
|
| Rate for Payer: Preferred Network Access Commercial |
$43.70
|
| Rate for Payer: Quartz Beloit One Network |
$20.24
|
| Rate for Payer: Quartz Commercial |
$26.22
|
| Rate for Payer: The Alliance Commercial |
$23.00
|
| Rate for Payer: WEA Trust Commercial |
$25.30
|
| Rate for Payer: WPS Commercial |
$34.07
|
|
|
BCR/ABL Extraction
|
Facility
IP
|
$46.00
|
|
| Hospital Charge Code |
2790799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$42.32 |
| Rate for Payer: Aetna Commercial |
$41.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.38
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$42.32
|
| Rate for Payer: Health EOS Commercial |
$40.94
|
| Rate for Payer: HFN Commercial |
$42.32
|
| Rate for Payer: Multiplan Commercial |
$36.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.60
|
| Rate for Payer: Preferred Network Access Commercial |
$42.32
|
| Rate for Payer: Quartz Beloit One Network |
$22.54
|
| Rate for Payer: Quartz Commercial |
$27.60
|
| Rate for Payer: WEA Trust Commercial |
$25.30
|
| Rate for Payer: WPS Commercial |
$34.07
|
|
|
BCR/ABL Extraction
|
Facility
OP
|
$46.00
|
|
| Hospital Charge Code |
2790799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.88 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$41.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.56
|
| Rate for Payer: Aetna Managed Medicare |
$12.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.38
|
| Rate for Payer: Cash Price |
$13.80
|
| Rate for Payer: Cigna Commercial |
$42.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.74
|
| Rate for Payer: Health EOS Commercial |
$40.94
|
| Rate for Payer: HFN Commercial |
$42.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34.50
|
| Rate for Payer: Multiplan Commercial |
$36.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.60
|
| Rate for Payer: Preferred Network Access Commercial |
$42.32
|
| Rate for Payer: Quartz Beloit One Network |
$22.54
|
| Rate for Payer: Quartz Commercial |
$29.90
|
| Rate for Payer: Quartz Medicare Advantage |
$27.60
|
| Rate for Payer: The Alliance Commercial |
$184.00
|
| Rate for Payer: United Healthcare PPO |
$34.50
|
| Rate for Payer: WEA Trust Commercial |
$25.30
|
| Rate for Payer: WPS Commercial |
$34.07
|
|
|
BCR/ABL Interp & Report
|
Professional
|
$56.00
|
|
| Hospital Charge Code |
2790800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.64 |
| Max. Negotiated Rate |
$53.20 |
| Rate for Payer: Aetna Commercial |
$53.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$53.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.60
|
| Rate for Payer: Health EOS Commercial |
$50.96
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.20
|
| Rate for Payer: Quartz Beloit One Network |
$24.64
|
| Rate for Payer: Quartz Commercial |
$31.92
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BCR/ABL Interp & Report
|
Facility
OP
|
$56.00
|
|
| Hospital Charge Code |
2790800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$224.00 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.16
|
| Rate for Payer: Aetna Managed Medicare |
$15.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.34
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.00
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$36.40
|
| Rate for Payer: Quartz Medicare Advantage |
$33.60
|
| Rate for Payer: The Alliance Commercial |
$224.00
|
| Rate for Payer: United Healthcare PPO |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BCR/ABL Interp & Report
|
Facility
IP
|
$56.00
|
|
| Hospital Charge Code |
2790800
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$51.52 |
| Rate for Payer: Aetna Commercial |
$50.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.68
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: Cigna Commercial |
$51.52
|
| Rate for Payer: Health EOS Commercial |
$49.84
|
| Rate for Payer: HFN Commercial |
$51.52
|
| Rate for Payer: Multiplan Commercial |
$44.80
|
| Rate for Payer: NAPHCARE Commercial |
$33.60
|
| Rate for Payer: Preferred Network Access Commercial |
$51.52
|
| Rate for Payer: Quartz Beloit One Network |
$27.44
|
| Rate for Payer: Quartz Commercial |
$33.60
|
| Rate for Payer: WEA Trust Commercial |
$30.80
|
| Rate for Payer: WPS Commercial |
$41.48
|
|
|
BCR/ABL Nucleic Acid Probe
|
Professional
|
$54.00
|
|
| Hospital Charge Code |
2790801
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$51.30 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
