|
Blood Transfusion 4 - 6 Hours
|
Facility
|
OP
|
$687.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
3040441
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$329.76 |
| Max. Negotiated Rate |
$11,874.87 |
| Rate for Payer: Aetna Commercial |
$618.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Aetna Managed Medicare |
$429.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$446.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$343.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$329.76
|
| Rate for Payer: Anthem Medicare Advantage |
$429.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$364.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$429.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$429.07
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$632.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$429.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$429.07
|
| Rate for Payer: Health EOS Commercial |
$611.43
|
| Rate for Payer: HFN Commercial |
$632.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,596.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$429.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$429.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$429.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$429.07
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: NAPHCARE Commercial |
$643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$632.04
|
| Rate for Payer: Quartz Beloit One Network |
$336.63
|
| Rate for Payer: Quartz Commercial |
$446.55
|
| Rate for Payer: Quartz Medicare Advantage |
$429.07
|
| Rate for Payer: The Alliance Commercial |
$1,716.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$429.07
|
| Rate for Payer: United Healthcare PPO |
$515.25
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: Wellcare Medicare |
$429.07
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
Blood Transfusion 4 - 6 Hours
|
Facility
|
IP
|
$687.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
3040441
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$336.63 |
| Max. Negotiated Rate |
$632.04 |
| Rate for Payer: Aetna Commercial |
$618.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$364.11
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$632.04
|
| Rate for Payer: Health EOS Commercial |
$611.43
|
| Rate for Payer: HFN Commercial |
$632.04
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: NAPHCARE Commercial |
$412.20
|
| Rate for Payer: Preferred Network Access Commercial |
$632.04
|
| Rate for Payer: Quartz Beloit One Network |
$336.63
|
| Rate for Payer: Quartz Commercial |
$412.20
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
Blood Transfusion 6 - 12 Hours
|
Facility
|
OP
|
$1,239.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
3040442
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$429.07 |
| Max. Negotiated Rate |
$11,874.87 |
| Rate for Payer: Aetna Commercial |
$1,115.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,065.54
|
| Rate for Payer: Aetna Managed Medicare |
$429.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$805.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$594.72
|
| Rate for Payer: Anthem Medicare Advantage |
$429.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$656.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$429.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$429.07
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cigna Commercial |
$1,139.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$429.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,874.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$429.07
|
| Rate for Payer: Health EOS Commercial |
$1,102.71
|
| Rate for Payer: HFN Commercial |
$1,139.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,596.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$429.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$429.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$429.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$429.07
|
| Rate for Payer: Multiplan Commercial |
$991.20
|
| Rate for Payer: NAPHCARE Commercial |
$643.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,139.88
|
| Rate for Payer: Quartz Beloit One Network |
$607.11
|
| Rate for Payer: Quartz Commercial |
$805.35
|
| Rate for Payer: Quartz Medicare Advantage |
$429.07
|
| Rate for Payer: The Alliance Commercial |
$1,716.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$429.07
|
| Rate for Payer: United Healthcare PPO |
$929.25
|
| Rate for Payer: WEA Trust Commercial |
$681.45
|
| Rate for Payer: Wellcare Medicare |
$429.07
|
| Rate for Payer: WPS Commercial |
$917.73
|
|
|
Blood Transfusion 6 - 12 Hours
|
Facility
|
IP
|
$1,239.00
|
|
|
Service Code
|
CPT 36430
|
| Hospital Charge Code |
3040442
|
|
Hospital Revenue Code
|
391
|
| Min. Negotiated Rate |
$607.11 |
| Max. Negotiated Rate |
$1,139.88 |
| Rate for Payer: Aetna Commercial |
$1,115.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,065.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$656.67
|
| Rate for Payer: Cash Price |
$371.70
|
| Rate for Payer: Cigna Commercial |
$1,139.88
|
| Rate for Payer: Health EOS Commercial |
$1,102.71
|
| Rate for Payer: HFN Commercial |
$1,139.88
|
| Rate for Payer: Multiplan Commercial |
$991.20
|
| Rate for Payer: NAPHCARE Commercial |
$743.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,139.88
|
| Rate for Payer: Quartz Beloit One Network |
$607.11
|
| Rate for Payer: Quartz Commercial |
$743.40
|
| Rate for Payer: WEA Trust Commercial |
$681.45
|
| Rate for Payer: WPS Commercial |
$917.73
|
|
|
Blood tubing, Hi Flo gravity - IV Equipment/Supplies
|
Facility
|
OP
|
$823.00
|
|
| Hospital Charge Code |
3000007
|
| Min. Negotiated Rate |
$230.44 |
| Max. Negotiated Rate |
$3,292.00 |
| Rate for Payer: Aetna Commercial |
$740.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.78
|
| Rate for Payer: Aetna Managed Medicare |
$230.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$534.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$411.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$395.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.19
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$757.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$460.55
|
| Rate for Payer: Health EOS Commercial |
$732.47
|
| Rate for Payer: HFN Commercial |
$757.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$617.25
|
| Rate for Payer: Multiplan Commercial |
$658.40
|
| Rate for Payer: NAPHCARE Commercial |
$493.80
|
| Rate for Payer: Preferred Network Access Commercial |
$757.16
|
| Rate for Payer: Quartz Beloit One Network |
$403.27
|
| Rate for Payer: Quartz Commercial |
$534.95
|
| Rate for Payer: Quartz Medicare Advantage |
$493.80
|
| Rate for Payer: The Alliance Commercial |
$3,292.00
|
| Rate for Payer: WEA Trust Commercial |
$452.65
|
| Rate for Payer: WPS Commercial |
$609.60
|
|
|
Blood tubing, Hi Flo gravity - IV Equipment/Supplies
|
Facility
|
IP
|
$823.00
|
|
| Hospital Charge Code |
3000007
|
| Min. Negotiated Rate |
$403.27 |
| Max. Negotiated Rate |
$757.16 |
| Rate for Payer: Aetna Commercial |
$740.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$707.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$436.19
|
| Rate for Payer: Cash Price |
$246.90
|
| Rate for Payer: Cigna Commercial |
$757.16
|
| Rate for Payer: Health EOS Commercial |
$732.47
|
| Rate for Payer: HFN Commercial |
$757.16
|
| Rate for Payer: Multiplan Commercial |
$658.40
|
| Rate for Payer: NAPHCARE Commercial |
$493.80
|
| Rate for Payer: Preferred Network Access Commercial |
$757.16
|
| Rate for Payer: Quartz Beloit One Network |
$403.27
|
| Rate for Payer: Quartz Commercial |
$493.80
|
| Rate for Payer: WEA Trust Commercial |
$452.65
|
| Rate for Payer: WPS Commercial |
$609.60
|
|
|
Blood tubing, Hi Flo gravity - Peripheral IV Equipment:
|
Facility
|
OP
|
$855.00
|
|
| Hospital Charge Code |
2999915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$239.40 |
| Max. Negotiated Rate |
$3,420.00 |
| Rate for Payer: Aetna Commercial |
$769.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.30
|
| Rate for Payer: Aetna Managed Medicare |
$239.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$410.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.15
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna Commercial |
$786.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$478.46
|
| Rate for Payer: Health EOS Commercial |
$760.95
|
| Rate for Payer: HFN Commercial |
$786.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$641.25
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: NAPHCARE Commercial |
$513.00
|
| Rate for Payer: Preferred Network Access Commercial |
$786.60
|
| Rate for Payer: Quartz Beloit One Network |
$418.95
|
| Rate for Payer: Quartz Commercial |
$555.75
|
| Rate for Payer: Quartz Medicare Advantage |
$513.00
|
| Rate for Payer: The Alliance Commercial |
$3,420.00
|
| Rate for Payer: WEA Trust Commercial |
$470.25
|
| Rate for Payer: WPS Commercial |
$633.30
|
|
|
Blood tubing, Hi Flo gravity - Peripheral IV Equipment:
|
Facility
|
IP
|
$855.00
|
|
| Hospital Charge Code |
2999915
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$418.95 |
| Max. Negotiated Rate |
$786.60 |
| Rate for Payer: Aetna Commercial |
$769.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$735.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$453.15
|
| Rate for Payer: Cash Price |
$256.50
|
| Rate for Payer: Cigna Commercial |
$786.60
|
| Rate for Payer: Health EOS Commercial |
$760.95
|
| Rate for Payer: HFN Commercial |
$786.60
|
| Rate for Payer: Multiplan Commercial |
$684.00
|
| Rate for Payer: NAPHCARE Commercial |
$513.00
|
| Rate for Payer: Preferred Network Access Commercial |
$786.60
|
| Rate for Payer: Quartz Beloit One Network |
$418.95
|
| Rate for Payer: Quartz Commercial |
$513.00
|
| Rate for Payer: WEA Trust Commercial |
$470.25
|
| Rate for Payer: WPS Commercial |
$633.30
|
|
|
Blood tubing, secondary - IV Equipment/Supplies
|
Facility
|
IP
|
$80.00
|
|
| Hospital Charge Code |
3000006
|
| Min. Negotiated Rate |
$39.20 |
| Max. Negotiated Rate |
$73.60 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$48.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
Blood tubing, secondary - IV Equipment/Supplies
|
Facility
|
OP
|
$80.00
|
|
| Hospital Charge Code |
3000006
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$72.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.80
|
| Rate for Payer: Aetna Managed Medicare |
$22.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$73.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.77
|
| Rate for Payer: Health EOS Commercial |
$71.20
|
| Rate for Payer: HFN Commercial |
$73.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.00
|
| Rate for Payer: Multiplan Commercial |
$64.00
|
| Rate for Payer: NAPHCARE Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$73.60
|
| Rate for Payer: Quartz Beloit One Network |
$39.20
|
| Rate for Payer: Quartz Commercial |
$52.00
|
| Rate for Payer: Quartz Medicare Advantage |
$48.00
|
| Rate for Payer: The Alliance Commercial |
$320.00
|
| Rate for Payer: WEA Trust Commercial |
$44.00
|
| Rate for Payer: WPS Commercial |
$59.26
|
|
|
Blood tubing, secondary - Peripheral IV Equipment:
|
Facility
|
IP
|
$82.00
|
|
| Hospital Charge Code |
2999914
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Blood tubing, secondary - Peripheral IV Equipment:
|
Facility
|
OP
|
$82.00
|
|
| Hospital Charge Code |
2999914
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Blood Type ABO/Rh Typing
|
Facility
|
OP
|
$108.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
634326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$473.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$220.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$209.59
|
| Rate for Payer: Anthem Medicaid |
$3.09
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.44
|
| Rate for Payer: Dean Health Medicaid |
$3.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicaid |
$3.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3.09
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$70.20
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicaid |
$3.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$81.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WMAP Medicaid |
$3.09
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Blood Type ABO/Rh Typing
|
Facility
|
IP
|
$108.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
634326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.92 |
| Max. Negotiated Rate |
$99.36 |
| Rate for Payer: Aetna Commercial |
$97.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.24
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$99.36
|
| Rate for Payer: Health EOS Commercial |
$96.12
|
| Rate for Payer: HFN Commercial |
$99.36
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: NAPHCARE Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$99.36
|
| Rate for Payer: Quartz Beloit One Network |
$52.92
|
| Rate for Payer: Quartz Commercial |
$64.80
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Blood Type ABO/Rh Typing
|
Professional
|
Both
|
$108.00
|
|
|
Service Code
|
CPT 86900
|
| Hospital Charge Code |
634326
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$102.60 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.88
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cash Price |
$32.40
|
| Rate for Payer: Cigna Commercial |
$102.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.80
|
| Rate for Payer: Health EOS Commercial |
$98.28
|
| Rate for Payer: HFN Commercial |
$102.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10.55
|
| Rate for Payer: Multiplan Commercial |
$86.40
|
| Rate for Payer: Preferred Network Access Commercial |
$102.60
|
| Rate for Payer: Quartz Beloit One Network |
$47.52
|
| Rate for Payer: Quartz Commercial |
$61.56
|
| Rate for Payer: The Alliance Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$59.40
|
| Rate for Payer: WPS Commercial |
$80.00
|
|
|
Blood Urea Nitrogen
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.94 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Aetna Commercial |
$72.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.60
|
| Rate for Payer: Health EOS Commercial |
$69.16
|
| Rate for Payer: HFN Commercial |
$72.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.94
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: Preferred Network Access Commercial |
$72.20
|
| Rate for Payer: Quartz Beloit One Network |
$33.44
|
| Rate for Payer: Quartz Commercial |
$43.32
|
| Rate for Payer: The Alliance Commercial |
$38.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Blood Urea Nitrogen
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$3.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.56
|
| Rate for Payer: Anthem Medicaid |
$4.08
|
| Rate for Payer: Anthem Medicare Advantage |
$3.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.95
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Dean Health Medicaid |
$4.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3.95
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.95
|
| Rate for Payer: Managed Health Services Medicaid |
$4.24
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3.95
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$5.92
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4.08
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3.95
|
| Rate for Payer: The Alliance Commercial |
$15.80
|
| Rate for Payer: United Healthcare Medicaid |
$4.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.95
|
| Rate for Payer: United Healthcare PPO |
$57.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: Wellcare Medicare |
$3.95
|
| Rate for Payer: WMAP Medicaid |
$4.08
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Blood Urea Nitrogen
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633605
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Blood volume removed from patient
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4125565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.17 |
| Max. Negotiated Rate |
$214.36 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$139.80
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
Blood volume removed from patient
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4125565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$111.84 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$151.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$116.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$111.84
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.39
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$151.45
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$174.75
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
Blood Volume Removed from Patient
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4582615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$134.75 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$165.00
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$165.00
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
Blood Volume Removed from Patient
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
4582615
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.26 |
| Max. Negotiated Rate |
$505.04 |
| Rate for Payer: Aetna Commercial |
$247.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.50
|
| Rate for Payer: Aetna Managed Medicare |
$126.26
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.00
|
| Rate for Payer: Anthem Medicare Advantage |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$126.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$126.26
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$253.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$126.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$126.26
|
| Rate for Payer: Health EOS Commercial |
$244.75
|
| Rate for Payer: HFN Commercial |
$253.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$469.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$126.26
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$126.26
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$126.26
|
| Rate for Payer: Multiplan Commercial |
$220.00
|
| Rate for Payer: NAPHCARE Commercial |
$189.39
|
| Rate for Payer: Preferred Network Access Commercial |
$253.00
|
| Rate for Payer: Quartz Beloit One Network |
$134.75
|
| Rate for Payer: Quartz Commercial |
$178.75
|
| Rate for Payer: Quartz Medicare Advantage |
$126.26
|
| Rate for Payer: The Alliance Commercial |
$505.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$126.26
|
| Rate for Payer: United Healthcare PPO |
$206.25
|
| Rate for Payer: WEA Trust Commercial |
$151.25
|
| Rate for Payer: Wellcare Medicare |
$126.26
|
| Rate for Payer: WPS Commercial |
$203.69
|
|
|
BLUEBAG BODYFIX 14 REC 700X1825MM/ 50L P10104-823
|
Facility
|
OP
|
$4,672.00
|
|
| Hospital Charge Code |
5248762
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,308.16 |
| Max. Negotiated Rate |
$18,688.00 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Aetna Managed Medicare |
$1,308.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,036.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,336.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,242.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,614.45
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,504.00
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$3,036.80
|
| Rate for Payer: Quartz Medicare Advantage |
$2,803.20
|
| Rate for Payer: The Alliance Commercial |
$18,688.00
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
BLUEBAG BODYFIX 14 REC 700X1825MM/ 50L P10104-823
|
Facility
|
IP
|
$4,672.00
|
|
| Hospital Charge Code |
5248762
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,289.28 |
| Max. Negotiated Rate |
$4,298.24 |
| Rate for Payer: Aetna Commercial |
$4,204.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,017.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,476.16
|
| Rate for Payer: Cash Price |
$1,401.60
|
| Rate for Payer: Cigna Commercial |
$4,298.24
|
| Rate for Payer: Health EOS Commercial |
$4,158.08
|
| Rate for Payer: HFN Commercial |
$4,298.24
|
| Rate for Payer: Multiplan Commercial |
$3,737.60
|
| Rate for Payer: NAPHCARE Commercial |
$2,803.20
|
| Rate for Payer: Preferred Network Access Commercial |
$4,298.24
|
| Rate for Payer: Quartz Beloit One Network |
$2,289.28
|
| Rate for Payer: Quartz Commercial |
$2,803.20
|
| Rate for Payer: WEA Trust Commercial |
$2,569.60
|
| Rate for Payer: WPS Commercial |
$3,460.55
|
|
|
Blue (prong O.D.: 3.5mm) - RAM Cannula
|
Facility
|
IP
|
$223.00
|
|
| Hospital Charge Code |
5983676
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
