|
CABLE/SLEEVE 2.0 6704-0-510
|
Facility
|
IP
|
$2,564.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,256.36 |
| Max. Negotiated Rate |
$2,358.88 |
| Rate for Payer: Aetna Commercial |
$2,307.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,358.92
|
| Rate for Payer: Cash Price |
$769.20
|
| Rate for Payer: Cigna Commercial |
$2,358.88
|
| Rate for Payer: Health EOS Commercial |
$2,281.96
|
| Rate for Payer: HFN Commercial |
$2,358.88
|
| Rate for Payer: Multiplan Commercial |
$2,051.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,358.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.36
|
| Rate for Payer: Quartz Commercial |
$1,538.40
|
| Rate for Payer: WEA Trust Commercial |
$1,410.20
|
| Rate for Payer: WPS Commercial |
$1,899.15
|
|
|
CABLE/SLEEVE 2.0 BEADED 3704-0-050
|
Facility
|
OP
|
$2,661.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$745.08 |
| Max. Negotiated Rate |
$10,644.00 |
| Rate for Payer: Aetna Commercial |
$2,394.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,288.46
|
| Rate for Payer: Aetna Managed Medicare |
$745.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,729.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,330.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,277.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,410.33
|
| Rate for Payer: Cash Price |
$798.30
|
| Rate for Payer: Cigna Commercial |
$2,448.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,489.10
|
| Rate for Payer: Health EOS Commercial |
$2,368.29
|
| Rate for Payer: HFN Commercial |
$2,448.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,995.75
|
| Rate for Payer: Multiplan Commercial |
$2,128.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,596.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,448.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.89
|
| Rate for Payer: Quartz Commercial |
$1,729.65
|
| Rate for Payer: Quartz Medicare Advantage |
$1,596.60
|
| Rate for Payer: The Alliance Commercial |
$10,644.00
|
| Rate for Payer: WEA Trust Commercial |
$1,463.55
|
| Rate for Payer: WPS Commercial |
$1,971.00
|
|
|
CABLE/SLEEVE 2.0 BEADED 3704-0-050
|
Facility
|
IP
|
$2,661.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.89 |
| Max. Negotiated Rate |
$2,448.12 |
| Rate for Payer: Aetna Commercial |
$2,394.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,288.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,410.33
|
| Rate for Payer: Cash Price |
$798.30
|
| Rate for Payer: Cigna Commercial |
$2,448.12
|
| Rate for Payer: Health EOS Commercial |
$2,368.29
|
| Rate for Payer: HFN Commercial |
$2,448.12
|
| Rate for Payer: Multiplan Commercial |
$2,128.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,596.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,448.12
|
| Rate for Payer: Quartz Beloit One Network |
$1,303.89
|
| Rate for Payer: Quartz Commercial |
$1,596.60
|
| Rate for Payer: WEA Trust Commercial |
$1,463.55
|
| Rate for Payer: WPS Commercial |
$1,971.00
|
|
|
CABLE SLEEVE 2.0MM MEDIUM 6704-4-020
|
Facility
|
OP
|
$1,664.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$465.92 |
| Max. Negotiated Rate |
$6,656.00 |
| Rate for Payer: Aetna Commercial |
$1,497.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,431.04
|
| Rate for Payer: Aetna Managed Medicare |
$465.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,081.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$832.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$798.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$881.92
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$1,530.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$931.17
|
| Rate for Payer: Health EOS Commercial |
$1,480.96
|
| Rate for Payer: HFN Commercial |
$1,530.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,248.00
|
| Rate for Payer: Multiplan Commercial |
$1,331.20
|
| Rate for Payer: NAPHCARE Commercial |
$998.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,530.88
|
| Rate for Payer: Quartz Beloit One Network |
$815.36
|
| Rate for Payer: Quartz Commercial |
$1,081.60
|
| Rate for Payer: Quartz Medicare Advantage |
$998.40
|
| Rate for Payer: The Alliance Commercial |
$6,656.00
|
| Rate for Payer: WEA Trust Commercial |
$915.20
|
| Rate for Payer: WPS Commercial |
$1,232.52
|
|
|
CABLE SLEEVE 2.0MM MEDIUM 6704-4-020
|
Facility
|
IP
|
$1,664.00
|
|
|
Service Code
|
HCPCS L8699
|
| Hospital Charge Code |
2966074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$815.36 |
| Max. Negotiated Rate |
$1,530.88 |
| Rate for Payer: Aetna Commercial |
$1,497.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,431.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$881.92
|
| Rate for Payer: Cash Price |
$499.20
|
| Rate for Payer: Cigna Commercial |
$1,530.88
|
| Rate for Payer: Health EOS Commercial |
$1,480.96
|
| Rate for Payer: HFN Commercial |
$1,530.88
|
| Rate for Payer: Multiplan Commercial |
$1,331.20
|
| Rate for Payer: NAPHCARE Commercial |
$998.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,530.88
|
| Rate for Payer: Quartz Beloit One Network |
$815.36
|
| Rate for Payer: Quartz Commercial |
$998.40
|
| Rate for Payer: WEA Trust Commercial |
$915.20
|
| Rate for Payer: WPS Commercial |
$1,232.52
|
|
|
Ca Channel Bind Antibody SN Type
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.34
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$91.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Ca Channel Bind Antibody SN Type
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Anthem Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
Ca Channel Bind Antibody SN Type
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942961
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
CA Channel Bind Antibody SP/Q Type
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.60 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$84.00
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$84.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
CA Channel Bind Antibody SP/Q Type
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.72 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Anthem Commercial |
$17.72
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
CA Channel Bind Antibody SP/Q Type
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 86596
|
| Hospital Charge Code |
2942960
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$128.80 |
| Rate for Payer: Aetna Commercial |
$126.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$128.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.34
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$124.60
|
| Rate for Payer: HFN Commercial |
$128.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$128.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$68.60
|
| Rate for Payer: Quartz Commercial |
$91.00
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
CAD for Screening Mammography
|
Facility
|
OP
|
$82.00
|
|
| Hospital Charge Code |
1158804
|
| 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
|
|
|
CAD for Screening Mammography
|
Facility
|
IP
|
$82.00
|
|
| Hospital Charge Code |
1158804
|
| 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
|
|
|
CAD for Screening Mammography
|
Professional
|
Both
|
$82.00
|
|
| Hospital Charge Code |
1158804
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$77.90 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$77.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.20
|
| Rate for Payer: Health EOS Commercial |
$74.62
|
| Rate for Payer: HFN Commercial |
$77.90
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: Preferred Network Access Commercial |
$77.90
|
| Rate for Payer: Quartz Beloit One Network |
$36.08
|
| Rate for Payer: Quartz Commercial |
$46.74
|
| Rate for Payer: The Alliance Commercial |
$41.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Cadmium Level
|
Facility
|
IP
|
$583.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
977891
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$285.67 |
| Max. Negotiated Rate |
$536.36 |
| Rate for Payer: Aetna Commercial |
$524.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$308.99
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cigna Commercial |
$536.36
|
| Rate for Payer: Health EOS Commercial |
$518.87
|
| Rate for Payer: HFN Commercial |
$536.36
|
| Rate for Payer: Multiplan Commercial |
$466.40
|
| Rate for Payer: NAPHCARE Commercial |
$349.80
|
| Rate for Payer: Preferred Network Access Commercial |
$536.36
|
| Rate for Payer: Quartz Beloit One Network |
$285.67
|
| Rate for Payer: Quartz Commercial |
$349.80
|
| Rate for Payer: WEA Trust Commercial |
$320.65
|
| Rate for Payer: WPS Commercial |
$431.83
|
|
|
Cadmium Level
|
Professional
|
Both
|
$583.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
977891
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.45 |
| Max. Negotiated Rate |
$553.85 |
| Rate for Payer: Aetna Commercial |
$553.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.38
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cigna Commercial |
$553.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$291.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$349.80
|
| Rate for Payer: Health EOS Commercial |
$530.53
|
| Rate for Payer: HFN Commercial |
$553.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.45
|
| Rate for Payer: Multiplan Commercial |
$466.40
|
| Rate for Payer: Preferred Network Access Commercial |
$553.85
|
| Rate for Payer: Quartz Beloit One Network |
$256.52
|
| Rate for Payer: Quartz Commercial |
$332.31
|
| Rate for Payer: The Alliance Commercial |
$291.50
|
| Rate for Payer: WEA Trust Commercial |
$320.65
|
| Rate for Payer: WPS Commercial |
$431.83
|
|
|
Cadmium Level
|
Facility
|
OP
|
$583.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
977891
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$536.36 |
| Rate for Payer: Aetna Commercial |
$524.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$501.38
|
| Rate for Payer: Aetna Managed Medicare |
$23.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.24
|
| Rate for Payer: Anthem Medicaid |
$24.43
|
| Rate for Payer: Anthem Medicare Advantage |
$23.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$308.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.64
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cash Price |
$174.90
|
| Rate for Payer: Cigna Commercial |
$536.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$326.25
|
| Rate for Payer: Dean Health Medicaid |
$24.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23.64
|
| Rate for Payer: Health EOS Commercial |
$518.87
|
| Rate for Payer: HFN Commercial |
$536.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.64
|
| Rate for Payer: Managed Health Services Medicaid |
$25.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23.64
|
| Rate for Payer: Multiplan Commercial |
$466.40
|
| Rate for Payer: NAPHCARE Commercial |
$35.46
|
| Rate for Payer: Preferred Network Access Commercial |
$536.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.43
|
| Rate for Payer: Quartz Beloit One Network |
$285.67
|
| Rate for Payer: Quartz Commercial |
$378.95
|
| Rate for Payer: Quartz Medicare Advantage |
$23.64
|
| Rate for Payer: The Alliance Commercial |
$94.56
|
| Rate for Payer: United Healthcare Medicaid |
$24.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.64
|
| Rate for Payer: United Healthcare PPO |
$437.25
|
| Rate for Payer: WEA Trust Commercial |
$320.65
|
| Rate for Payer: Wellcare Medicare |
$23.64
|
| Rate for Payer: WMAP Medicaid |
$24.43
|
| Rate for Payer: WPS Commercial |
$431.83
|
|
|
Cadmium, Occupational Exposure, Random, Urine
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
6173611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.61 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$53.40
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Cadmium, Occupational Exposure, Random, Urine
|
Facility
|
OP
|
$89.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
6173611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.64 |
| Max. Negotiated Rate |
$94.56 |
| Rate for Payer: Aetna Commercial |
$80.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Aetna Managed Medicare |
$23.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$88.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.24
|
| Rate for Payer: Anthem Medicaid |
$24.43
|
| Rate for Payer: Anthem Medicare Advantage |
$23.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$23.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$23.64
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$81.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$23.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.43
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.80
|
| Rate for Payer: Dean Health Medicaid |
$24.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$23.64
|
| Rate for Payer: Health EOS Commercial |
$79.21
|
| Rate for Payer: HFN Commercial |
$81.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$87.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$23.64
|
| Rate for Payer: Managed Health Services Medicaid |
$25.41
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$23.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$23.64
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: NAPHCARE Commercial |
$35.46
|
| Rate for Payer: Preferred Network Access Commercial |
$81.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.43
|
| Rate for Payer: Quartz Beloit One Network |
$43.61
|
| Rate for Payer: Quartz Commercial |
$57.85
|
| Rate for Payer: Quartz Medicare Advantage |
$23.64
|
| Rate for Payer: The Alliance Commercial |
$94.56
|
| Rate for Payer: United Healthcare Medicaid |
$24.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$23.64
|
| Rate for Payer: United Healthcare PPO |
$66.75
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: Wellcare Medicare |
$23.64
|
| Rate for Payer: WMAP Medicaid |
$24.43
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Cadmium, Occupational Exposure, Random, Urine
|
Professional
|
Both
|
$89.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
6173611
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$84.55 |
| Rate for Payer: Aetna Commercial |
$84.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$76.54
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cigna Commercial |
$84.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$44.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.40
|
| Rate for Payer: Health EOS Commercial |
$80.99
|
| Rate for Payer: HFN Commercial |
$84.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.45
|
| Rate for Payer: Multiplan Commercial |
$71.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.55
|
| Rate for Payer: Quartz Beloit One Network |
$39.16
|
| Rate for Payer: Quartz Commercial |
$50.73
|
| Rate for Payer: The Alliance Commercial |
$44.50
|
| Rate for Payer: WEA Trust Commercial |
$48.95
|
| Rate for Payer: WPS Commercial |
$65.92
|
|
|
Caffeine Level
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
CPT 80155
|
| Hospital Charge Code |
977893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$142.80
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$142.80
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
Caffeine Level
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
CPT 80155
|
| Hospital Charge Code |
977893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.72 |
| Max. Negotiated Rate |
$226.10 |
| Rate for Payer: Aetna Commercial |
$226.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$226.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$119.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$142.80
|
| Rate for Payer: Health EOS Commercial |
$216.58
|
| Rate for Payer: HFN Commercial |
$226.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.15
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: Preferred Network Access Commercial |
$226.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.72
|
| Rate for Payer: Quartz Commercial |
$135.66
|
| Rate for Payer: The Alliance Commercial |
$119.00
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
Caffeine Level
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
CPT 80155
|
| Hospital Charge Code |
977893
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.44 |
| Max. Negotiated Rate |
$218.96 |
| Rate for Payer: Aetna Commercial |
$214.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$204.68
|
| Rate for Payer: Aetna Managed Medicare |
$38.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$67.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$64.03
|
| Rate for Payer: Anthem Medicaid |
$15.44
|
| Rate for Payer: Anthem Medicare Advantage |
$38.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$126.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$38.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$38.57
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$218.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$38.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.18
|
| Rate for Payer: Dean Health Medicaid |
$15.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$38.57
|
| Rate for Payer: Health EOS Commercial |
$211.82
|
| Rate for Payer: HFN Commercial |
$218.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$38.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$38.57
|
| Rate for Payer: Managed Health Services Medicaid |
$16.06
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$38.57
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$38.57
|
| Rate for Payer: Multiplan Commercial |
$190.40
|
| Rate for Payer: NAPHCARE Commercial |
$57.86
|
| Rate for Payer: Preferred Network Access Commercial |
$218.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.44
|
| Rate for Payer: Quartz Beloit One Network |
$116.62
|
| Rate for Payer: Quartz Commercial |
$154.70
|
| Rate for Payer: Quartz Medicare Advantage |
$38.57
|
| Rate for Payer: The Alliance Commercial |
$154.28
|
| Rate for Payer: United Healthcare Medicaid |
$15.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$38.57
|
| Rate for Payer: United Healthcare PPO |
$178.50
|
| Rate for Payer: WEA Trust Commercial |
$130.90
|
| Rate for Payer: Wellcare Medicare |
$38.57
|
| Rate for Payer: WMAP Medicaid |
$15.44
|
| Rate for Payer: WPS Commercial |
$176.29
|
|
|
Caffeine, Urine
|
Facility
|
IP
|
$109.00
|
|
|
Service Code
|
CPT 80155
|
| Hospital Charge Code |
3313617
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.41 |
| Max. Negotiated Rate |
$100.28 |
| Rate for Payer: Aetna Commercial |
$98.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.77
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$100.28
|
| Rate for Payer: Health EOS Commercial |
$97.01
|
| Rate for Payer: HFN Commercial |
$100.28
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: NAPHCARE Commercial |
$65.40
|
| Rate for Payer: Preferred Network Access Commercial |
$100.28
|
| Rate for Payer: Quartz Beloit One Network |
$53.41
|
| Rate for Payer: Quartz Commercial |
$65.40
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
|
Caffeine, Urine
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
CPT 80155
|
| Hospital Charge Code |
3313617
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.96 |
| Max. Negotiated Rate |
$136.15 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.74
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$54.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$65.40
|
| Rate for Payer: Health EOS Commercial |
$99.19
|
| Rate for Payer: HFN Commercial |
$103.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.15
|
| Rate for Payer: Multiplan Commercial |
$87.20
|
| Rate for Payer: Preferred Network Access Commercial |
$103.55
|
| Rate for Payer: Quartz Beloit One Network |
$47.96
|
| Rate for Payer: Quartz Commercial |
$62.13
|
| Rate for Payer: The Alliance Commercial |
$54.50
|
| Rate for Payer: WEA Trust Commercial |
$59.95
|
| Rate for Payer: WPS Commercial |
$80.74
|
|
