|
Borrelia Sp DNA PCR Blood
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6180583
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$155.82 |
| Max. Negotiated Rate |
$292.56 |
| Rate for Payer: Aetna Commercial |
$286.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.54
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$292.56
|
| Rate for Payer: Health EOS Commercial |
$283.02
|
| Rate for Payer: HFN Commercial |
$292.56
|
| Rate for Payer: Multiplan Commercial |
$254.40
|
| Rate for Payer: NAPHCARE Commercial |
$190.80
|
| Rate for Payer: Preferred Network Access Commercial |
$292.56
|
| Rate for Payer: Quartz Beloit One Network |
$155.82
|
| Rate for Payer: Quartz Commercial |
$190.80
|
| Rate for Payer: WEA Trust Commercial |
$174.90
|
| Rate for Payer: WPS Commercial |
$235.54
|
|
|
Borrelia Sp DNA PCR Blood
|
Professional
|
Both
|
$318.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6180583
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.92 |
| Max. Negotiated Rate |
$302.10 |
| Rate for Payer: Aetna Commercial |
$302.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.48
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$302.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$159.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$190.80
|
| Rate for Payer: Health EOS Commercial |
$289.38
|
| Rate for Payer: HFN Commercial |
$302.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$247.81
|
| Rate for Payer: Multiplan Commercial |
$254.40
|
| Rate for Payer: Preferred Network Access Commercial |
$302.10
|
| Rate for Payer: Quartz Beloit One Network |
$139.92
|
| Rate for Payer: Quartz Commercial |
$181.26
|
| Rate for Payer: The Alliance Commercial |
$159.00
|
| Rate for Payer: WEA Trust Commercial |
$174.90
|
| Rate for Payer: WPS Commercial |
$235.54
|
|
|
Borrelia Sp DNA PCR Blood
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6180583
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$292.56 |
| Rate for Payer: Aetna Commercial |
$286.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$273.48
|
| Rate for Payer: Aetna Managed Medicare |
$70.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.53
|
| Rate for Payer: Anthem Medicaid |
$50.62
|
| Rate for Payer: Anthem Medicare Advantage |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$168.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$70.20
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cash Price |
$95.40
|
| Rate for Payer: Cigna Commercial |
$292.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$70.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$177.95
|
| Rate for Payer: Dean Health Medicaid |
$50.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$70.20
|
| Rate for Payer: Health EOS Commercial |
$283.02
|
| Rate for Payer: HFN Commercial |
$292.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$70.20
|
| Rate for Payer: Managed Health Services Medicaid |
$52.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$70.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$254.40
|
| Rate for Payer: NAPHCARE Commercial |
$105.30
|
| Rate for Payer: Preferred Network Access Commercial |
$292.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$50.62
|
| Rate for Payer: Quartz Beloit One Network |
$155.82
|
| Rate for Payer: Quartz Commercial |
$206.70
|
| Rate for Payer: Quartz Medicare Advantage |
$70.20
|
| Rate for Payer: The Alliance Commercial |
$280.80
|
| Rate for Payer: United Healthcare Medicaid |
$50.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.20
|
| Rate for Payer: United Healthcare PPO |
$238.50
|
| Rate for Payer: WEA Trust Commercial |
$174.90
|
| Rate for Payer: Wellcare Medicare |
$70.20
|
| Rate for Payer: WMAP Medicaid |
$50.62
|
| Rate for Payer: WPS Commercial |
$235.54
|
|
|
Borrelia SPP PCR w/Rflx SYNF & CSF
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6210448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$216.20 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$141.00
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$141.00
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
Borrelia SPP PCR w/Rflx SYNF & CSF
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6210448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$280.80 |
| Rate for Payer: Aetna Commercial |
$211.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Aetna Managed Medicare |
$70.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$116.53
|
| Rate for Payer: Anthem Medicaid |
$50.62
|
| Rate for Payer: Anthem Medicare Advantage |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$70.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$70.20
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$216.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$70.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$131.51
|
| Rate for Payer: Dean Health Medicaid |
$50.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$70.20
|
| Rate for Payer: Health EOS Commercial |
$209.15
|
| Rate for Payer: HFN Commercial |
$216.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$261.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$70.20
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$50.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$70.20
|
| Rate for Payer: Managed Health Services Medicaid |
$52.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$70.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.30
|
| Rate for Payer: Preferred Network Access Commercial |
$216.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$50.62
|
| Rate for Payer: Quartz Beloit One Network |
$115.15
|
| Rate for Payer: Quartz Commercial |
$152.75
|
| Rate for Payer: Quartz Medicare Advantage |
$70.20
|
| Rate for Payer: The Alliance Commercial |
$280.80
|
| Rate for Payer: United Healthcare Medicaid |
$50.62
|
| Rate for Payer: United Healthcare Medicare Advantage |
$70.20
|
| Rate for Payer: United Healthcare PPO |
$176.25
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: Wellcare Medicare |
$70.20
|
| Rate for Payer: WMAP Medicaid |
$50.62
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
Borrelia SPP PCR w/Rflx SYNF & CSF
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
6210448
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.40 |
| Max. Negotiated Rate |
$247.81 |
| Rate for Payer: Aetna Commercial |
$223.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$202.10
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cigna Commercial |
$223.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.00
|
| Rate for Payer: Health EOS Commercial |
$213.85
|
| Rate for Payer: HFN Commercial |
$223.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$247.81
|
| Rate for Payer: Multiplan Commercial |
$188.00
|
| Rate for Payer: Preferred Network Access Commercial |
$223.25
|
| Rate for Payer: Quartz Beloit One Network |
$103.40
|
| Rate for Payer: Quartz Commercial |
$133.95
|
| Rate for Payer: The Alliance Commercial |
$117.50
|
| Rate for Payer: WEA Trust Commercial |
$129.25
|
| Rate for Payer: WPS Commercial |
$174.06
|
|
|
Botox Cosmetic 1 Unit Charge
|
Professional
|
Both
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
2958911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.32
|
| Rate for Payer: Health EOS Commercial |
$15.47
|
| Rate for Payer: HFN Commercial |
$16.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.85
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16.15
|
| Rate for Payer: Quartz Beloit One Network |
$7.48
|
| Rate for Payer: Quartz Commercial |
$9.69
|
| Rate for Payer: The Alliance Commercial |
$8.50
|
| Rate for Payer: United Healthcare Medicaid |
$6.32
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
Botox Cosmetic 1 Unit Charge
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
2958911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.64 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$10.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$10.20
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$12.59
|
|
|
Botox Cosmetic 1 Unit Charge
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
2958911
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Aetna Managed Medicare |
$6.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.16
|
| Rate for Payer: Anthem Medicare Advantage |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.33
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.33
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.33
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.49
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$11.05
|
| Rate for Payer: Quartz Medicare Advantage |
$6.33
|
| Rate for Payer: The Alliance Commercial |
$25.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: Wellcare Medicare |
$6.33
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
BOTTLE PREVAC W/TUBING 1000ML SV1000-S/SV1000-NS
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4353486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$303.60 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$198.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
BOTTLE PREVAC W/TUBING 1000ML SV1000-S/SV1000-NS
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS A7048
|
| Hospital Charge Code |
4353486
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$1,320.00 |
| Rate for Payer: Aetna Commercial |
$297.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$283.80
|
| Rate for Payer: Aetna Managed Medicare |
$92.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$214.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$165.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$174.90
|
| Rate for Payer: Cash Price |
$99.00
|
| Rate for Payer: Cigna Commercial |
$303.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$184.67
|
| Rate for Payer: Health EOS Commercial |
$293.70
|
| Rate for Payer: HFN Commercial |
$303.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$247.50
|
| Rate for Payer: Multiplan Commercial |
$264.00
|
| Rate for Payer: NAPHCARE Commercial |
$198.00
|
| Rate for Payer: Preferred Network Access Commercial |
$303.60
|
| Rate for Payer: Quartz Beloit One Network |
$161.70
|
| Rate for Payer: Quartz Commercial |
$214.50
|
| Rate for Payer: Quartz Medicare Advantage |
$198.00
|
| Rate for Payer: The Alliance Commercial |
$1,320.00
|
| Rate for Payer: WEA Trust Commercial |
$181.50
|
| Rate for Payer: WPS Commercial |
$244.43
|
|
|
Botulinum toxin 1 U J0585
|
Professional
|
Both
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$16.15 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$16.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.32
|
| Rate for Payer: Health EOS Commercial |
$15.47
|
| Rate for Payer: HFN Commercial |
$16.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.85
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: Preferred Network Access Commercial |
$16.15
|
| Rate for Payer: Quartz Beloit One Network |
$7.48
|
| Rate for Payer: Quartz Commercial |
$9.69
|
| Rate for Payer: The Alliance Commercial |
$8.50
|
| Rate for Payer: United Healthcare Medicaid |
$6.32
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
Botulinum toxin 1 U J0585
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$25.31 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Aetna Managed Medicare |
$6.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.16
|
| Rate for Payer: Anthem Medicare Advantage |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.33
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.33
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.33
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$9.49
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$11.05
|
| Rate for Payer: Quartz Medicare Advantage |
$6.33
|
| Rate for Payer: The Alliance Commercial |
$25.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: Wellcare Medicare |
$6.33
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
Botulinum toxin 1 U J0585
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3382870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$15.64 |
| Rate for Payer: Aetna Commercial |
$15.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.01
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$15.64
|
| Rate for Payer: Health EOS Commercial |
$15.13
|
| Rate for Payer: HFN Commercial |
$15.64
|
| Rate for Payer: Multiplan Commercial |
$13.60
|
| Rate for Payer: NAPHCARE Commercial |
$10.20
|
| Rate for Payer: Preferred Network Access Commercial |
$15.64
|
| Rate for Payer: Quartz Beloit One Network |
$8.33
|
| Rate for Payer: Quartz Commercial |
$10.20
|
| Rate for Payer: WEA Trust Commercial |
$9.35
|
| Rate for Payer: WPS Commercial |
$12.59
|
|
|
BOWL CELL SAVER MINI 70 ML 0291A-00
|
Facility
|
IP
|
$2,288.00
|
|
| Hospital Charge Code |
2962860
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,121.12 |
| Max. Negotiated Rate |
$2,104.96 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,967.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,372.80
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BOWL CELL SAVER MINI 70 ML 0291A-00
|
Facility
|
OP
|
$2,288.00
|
|
| Hospital Charge Code |
2962860
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$640.64 |
| Max. Negotiated Rate |
$9,152.00 |
| Rate for Payer: Aetna Commercial |
$2,059.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,967.68
|
| Rate for Payer: Aetna Managed Medicare |
$640.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,487.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,144.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,098.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,212.64
|
| Rate for Payer: Cash Price |
$686.40
|
| Rate for Payer: Cigna Commercial |
$2,104.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,280.36
|
| Rate for Payer: Health EOS Commercial |
$2,036.32
|
| Rate for Payer: HFN Commercial |
$2,104.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,716.00
|
| Rate for Payer: Multiplan Commercial |
$1,830.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,372.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,104.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,121.12
|
| Rate for Payer: Quartz Commercial |
$1,487.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,372.80
|
| Rate for Payer: The Alliance Commercial |
$9,152.00
|
| Rate for Payer: WEA Trust Commercial |
$1,258.40
|
| Rate for Payer: WPS Commercial |
$1,694.72
|
|
|
BOWL CEMENT MIXEVAC III 0206-015-000
|
Facility
|
OP
|
$944.00
|
|
| Hospital Charge Code |
4089812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.32 |
| Max. Negotiated Rate |
$3,776.00 |
| Rate for Payer: Aetna Commercial |
$849.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$811.84
|
| Rate for Payer: Aetna Managed Medicare |
$264.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$613.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$472.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$453.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$500.32
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$868.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$528.26
|
| Rate for Payer: Health EOS Commercial |
$840.16
|
| Rate for Payer: HFN Commercial |
$868.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$708.00
|
| Rate for Payer: Multiplan Commercial |
$755.20
|
| Rate for Payer: NAPHCARE Commercial |
$566.40
|
| Rate for Payer: Preferred Network Access Commercial |
$868.48
|
| Rate for Payer: Quartz Beloit One Network |
$462.56
|
| Rate for Payer: Quartz Commercial |
$613.60
|
| Rate for Payer: Quartz Medicare Advantage |
$566.40
|
| Rate for Payer: The Alliance Commercial |
$3,776.00
|
| Rate for Payer: WEA Trust Commercial |
$519.20
|
| Rate for Payer: WPS Commercial |
$699.22
|
|
|
BOWL CEMENT MIXEVAC III 0206-015-000
|
Facility
|
IP
|
$944.00
|
|
| Hospital Charge Code |
4089812
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.56 |
| Max. Negotiated Rate |
$868.48 |
| Rate for Payer: Aetna Commercial |
$849.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$811.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$500.32
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$868.48
|
| Rate for Payer: Health EOS Commercial |
$840.16
|
| Rate for Payer: HFN Commercial |
$868.48
|
| Rate for Payer: Multiplan Commercial |
$755.20
|
| Rate for Payer: NAPHCARE Commercial |
$566.40
|
| Rate for Payer: Preferred Network Access Commercial |
$868.48
|
| Rate for Payer: Quartz Beloit One Network |
$462.56
|
| Rate for Payer: Quartz Commercial |
$566.40
|
| Rate for Payer: WEA Trust Commercial |
$519.20
|
| Rate for Payer: WPS Commercial |
$699.22
|
|
|
BOWL GUIDEWIRE 2500ML/84 OZ DYNJGUIDEWIRE
|
Facility
|
IP
|
$176.00
|
|
| Hospital Charge Code |
6217079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$86.24 |
| Max. Negotiated Rate |
$161.92 |
| Rate for Payer: Aetna Commercial |
$158.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$151.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.28
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$161.92
|
| Rate for Payer: Health EOS Commercial |
$156.64
|
| Rate for Payer: HFN Commercial |
$161.92
|
| Rate for Payer: Multiplan Commercial |
$140.80
|
| Rate for Payer: NAPHCARE Commercial |
$105.60
|
| Rate for Payer: Preferred Network Access Commercial |
$161.92
|
| Rate for Payer: Quartz Beloit One Network |
$86.24
|
| Rate for Payer: Quartz Commercial |
$105.60
|
| Rate for Payer: WEA Trust Commercial |
$96.80
|
| Rate for Payer: WPS Commercial |
$130.36
|
|
|
BOWL GUIDEWIRE 2500ML/84 OZ DYNJGUIDEWIRE
|
Facility
|
OP
|
$176.00
|
|
| Hospital Charge Code |
6217079
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$704.00 |
| Rate for Payer: Aetna Commercial |
$158.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$151.36
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$88.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$93.28
|
| Rate for Payer: Cash Price |
$52.80
|
| Rate for Payer: Cigna Commercial |
$161.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$98.49
|
| Rate for Payer: Health EOS Commercial |
$156.64
|
| Rate for Payer: HFN Commercial |
$161.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$132.00
|
| Rate for Payer: Multiplan Commercial |
$140.80
|
| Rate for Payer: NAPHCARE Commercial |
$105.60
|
| Rate for Payer: Preferred Network Access Commercial |
$161.92
|
| Rate for Payer: Quartz Beloit One Network |
$86.24
|
| Rate for Payer: Quartz Commercial |
$114.40
|
| Rate for Payer: Quartz Medicare Advantage |
$105.60
|
| Rate for Payer: The Alliance Commercial |
$704.00
|
| Rate for Payer: WEA Trust Commercial |
$96.80
|
| Rate for Payer: WPS Commercial |
$130.36
|
|
|
BRACE ANKLE DEROYAL #AB2340-06
|
Facility
|
OP
|
$438.00
|
|
| Hospital Charge Code |
2969578
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$122.64 |
| Max. Negotiated Rate |
$1,752.00 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Aetna Managed Medicare |
$122.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$284.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$219.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$210.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.10
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$328.50
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$284.70
|
| Rate for Payer: Quartz Medicare Advantage |
$262.80
|
| Rate for Payer: The Alliance Commercial |
$1,752.00
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
BRACE ANKLE DEROYAL #AB2340-06
|
Facility
|
IP
|
$438.00
|
|
| Hospital Charge Code |
2969578
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$214.62 |
| Max. Negotiated Rate |
$402.96 |
| Rate for Payer: Aetna Commercial |
$394.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$376.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$232.14
|
| Rate for Payer: Cash Price |
$131.40
|
| Rate for Payer: Cigna Commercial |
$402.96
|
| Rate for Payer: Health EOS Commercial |
$389.82
|
| Rate for Payer: HFN Commercial |
$402.96
|
| Rate for Payer: Multiplan Commercial |
$350.40
|
| Rate for Payer: NAPHCARE Commercial |
$262.80
|
| Rate for Payer: Preferred Network Access Commercial |
$402.96
|
| Rate for Payer: Quartz Beloit One Network |
$214.62
|
| Rate for Payer: Quartz Commercial |
$262.80
|
| Rate for Payer: WEA Trust Commercial |
$240.90
|
| Rate for Payer: WPS Commercial |
$324.43
|
|
|
BRACE ANKLE LT SM 02CL
|
Facility
|
IP
|
$417.00
|
|
| Hospital Charge Code |
2974433
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$204.33 |
| Max. Negotiated Rate |
$383.64 |
| Rate for Payer: Aetna Commercial |
$375.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.01
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$383.64
|
| Rate for Payer: Health EOS Commercial |
$371.13
|
| Rate for Payer: HFN Commercial |
$383.64
|
| Rate for Payer: Multiplan Commercial |
$333.60
|
| Rate for Payer: NAPHCARE Commercial |
$250.20
|
| Rate for Payer: Preferred Network Access Commercial |
$383.64
|
| Rate for Payer: Quartz Beloit One Network |
$204.33
|
| Rate for Payer: Quartz Commercial |
$250.20
|
| Rate for Payer: WEA Trust Commercial |
$229.35
|
| Rate for Payer: WPS Commercial |
$308.87
|
|
|
BRACE ANKLE LT SM 02CL
|
Facility
|
OP
|
$417.00
|
|
| Hospital Charge Code |
2974433
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$116.76 |
| Max. Negotiated Rate |
$1,668.00 |
| Rate for Payer: Aetna Commercial |
$375.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$358.62
|
| Rate for Payer: Aetna Managed Medicare |
$116.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$271.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$208.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$200.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$221.01
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$383.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$233.35
|
| Rate for Payer: Health EOS Commercial |
$371.13
|
| Rate for Payer: HFN Commercial |
$383.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$312.75
|
| Rate for Payer: Multiplan Commercial |
$333.60
|
| Rate for Payer: NAPHCARE Commercial |
$250.20
|
| Rate for Payer: Preferred Network Access Commercial |
$383.64
|
| Rate for Payer: Quartz Beloit One Network |
$204.33
|
| Rate for Payer: Quartz Commercial |
$271.05
|
| Rate for Payer: Quartz Medicare Advantage |
$250.20
|
| Rate for Payer: The Alliance Commercial |
$1,668.00
|
| Rate for Payer: WEA Trust Commercial |
$229.35
|
| Rate for Payer: WPS Commercial |
$308.87
|
|
|
BRACE ANKLE STANDARD LRG/RT
|
Facility
|
IP
|
$384.00
|
|
| Hospital Charge Code |
2969660
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$188.16 |
| Max. Negotiated Rate |
$353.28 |
| Rate for Payer: Aetna Commercial |
$345.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.52
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$353.28
|
| Rate for Payer: Health EOS Commercial |
$341.76
|
| Rate for Payer: HFN Commercial |
$353.28
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: NAPHCARE Commercial |
$230.40
|
| Rate for Payer: Preferred Network Access Commercial |
$353.28
|
| Rate for Payer: Quartz Beloit One Network |
$188.16
|
| Rate for Payer: Quartz Commercial |
$230.40
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
