|
DISTAL SPACER ACCOLADE LG 13MM 1059-6713
|
Facility
|
IP
|
$860.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5813623
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$438.26 |
| Max. Negotiated Rate |
$822.85 |
| Rate for Payer: Aetna Commercial |
$804.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$769.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$474.03
|
| Rate for Payer: Cash Price |
$258.00
|
| Rate for Payer: Cigna Commercial |
$822.85
|
| Rate for Payer: Health EOS Commercial |
$796.02
|
| Rate for Payer: HFN Commercial |
$822.85
|
| Rate for Payer: Multiplan Commercial |
$715.52
|
| Rate for Payer: Preferred Network Access Commercial |
$822.85
|
| Rate for Payer: Quartz Beloit One Network |
$438.26
|
| Rate for Payer: Quartz Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$491.92
|
| Rate for Payer: WPS Commercial |
$662.46
|
|
|
DISTRACTOR UC HIP SUPINE 72202207
|
Facility
|
OP
|
$5,533.00
|
|
| Hospital Charge Code |
5286795
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1,611.21 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,611.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,740.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,877.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,762.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,220.21
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,315.74
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: NAPHCARE Commercial |
$3,452.59
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,740.31
|
| Rate for Payer: Quartz Medicare Advantage |
$3,452.59
|
| Rate for Payer: The Alliance Commercial |
$2,877.16
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
DISTRACTOR UC HIP SUPINE 72202207
|
Facility
|
IP
|
$5,533.00
|
|
| Hospital Charge Code |
5286795
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2,819.62 |
| Max. Negotiated Rate |
$5,293.97 |
| Rate for Payer: Aetna Commercial |
$5,178.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,948.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,049.79
|
| Rate for Payer: Cash Price |
$1,659.90
|
| Rate for Payer: Cigna Commercial |
$5,293.97
|
| Rate for Payer: Health EOS Commercial |
$5,121.34
|
| Rate for Payer: HFN Commercial |
$5,293.97
|
| Rate for Payer: Multiplan Commercial |
$4,603.46
|
| Rate for Payer: Preferred Network Access Commercial |
$5,293.97
|
| Rate for Payer: Quartz Beloit One Network |
$2,819.62
|
| Rate for Payer: Quartz Commercial |
$3,452.59
|
| Rate for Payer: WEA Trust Commercial |
$3,164.88
|
| Rate for Payer: WPS Commercial |
$4,262.07
|
|
|
Disulfiram Level
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$238.11 |
| Rate for Payer: Aetna Commercial |
$238.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$238.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$228.08
|
| Rate for Payer: HFN Commercial |
$238.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$238.11
|
| Rate for Payer: Quartz Beloit One Network |
$110.28
|
| Rate for Payer: Quartz Commercial |
$142.86
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Disulfiram Level
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$162.92
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$187.98
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
Disulfiram Level
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
4010555
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$122.81 |
| Max. Negotiated Rate |
$230.59 |
| Rate for Payer: Aetna Commercial |
$225.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$215.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$132.84
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$230.59
|
| Rate for Payer: Health EOS Commercial |
$223.07
|
| Rate for Payer: HFN Commercial |
$230.59
|
| Rate for Payer: Multiplan Commercial |
$200.51
|
| Rate for Payer: Preferred Network Access Commercial |
$230.59
|
| Rate for Payer: Quartz Beloit One Network |
$122.81
|
| Rate for Payer: Quartz Commercial |
$150.38
|
| Rate for Payer: WEA Trust Commercial |
$137.85
|
| Rate for Payer: WPS Commercial |
$185.64
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$4,647.20
|
|
|
Service Code
|
APR-DRG 2441
|
| Min. Negotiated Rate |
$4,127.94 |
| Max. Negotiated Rate |
$4,647.20 |
| Rate for Payer: Anthem Medicaid |
$4,449.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$4,449.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,449.95
|
| Rate for Payer: Dean Health Medicaid |
$4,449.95
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,127.94
|
| Rate for Payer: Managed Health Services Medicaid |
$4,647.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,449.95
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$4,449.95
|
| Rate for Payer: United Healthcare Medicaid |
$4,449.95
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$6,400.87
|
|
|
Service Code
|
APR-DRG 2442
|
| Min. Negotiated Rate |
$5,685.65 |
| Max. Negotiated Rate |
$6,400.87 |
| Rate for Payer: Anthem Medicaid |
$6,129.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,129.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,129.18
|
| Rate for Payer: Dean Health Medicaid |
$6,129.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,685.65
|
| Rate for Payer: Managed Health Services Medicaid |
$6,400.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,129.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,129.18
|
| Rate for Payer: United Healthcare Medicaid |
$6,129.18
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
OP
|
$95.65
|
|
|
Service Code
|
EAPG 00616
|
| Min. Negotiated Rate |
$91.97 |
| Max. Negotiated Rate |
$95.65 |
| Rate for Payer: Anthem Medicaid |
$91.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$91.97
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91.97
|
| Rate for Payer: Dean Health Medicaid |
$91.97
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$91.97
|
| Rate for Payer: Managed Health Services Medicaid |
$95.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$91.97
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$91.97
|
| Rate for Payer: United Healthcare Medicaid |
$91.97
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$18,325.77
|
|
|
Service Code
|
APR-DRG 2444
|
| Min. Negotiated Rate |
$16,278.09 |
| Max. Negotiated Rate |
$18,325.77 |
| Rate for Payer: Anthem Medicaid |
$17,547.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$17,547.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17,547.93
|
| Rate for Payer: Dean Health Medicaid |
$17,547.93
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16,278.09
|
| Rate for Payer: Managed Health Services Medicaid |
$18,325.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$17,547.93
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17,547.93
|
| Rate for Payer: United Healthcare Medicaid |
$17,547.93
|
|
|
DIVERTICULITIS AND DIVERTICULOSIS
|
Facility
|
IP
|
$9,995.87
|
|
|
Service Code
|
APR-DRG 2443
|
| Min. Negotiated Rate |
$8,878.96 |
| Max. Negotiated Rate |
$9,995.87 |
| Rate for Payer: Anthem Medicaid |
$9,571.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,571.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,571.60
|
| Rate for Payer: Dean Health Medicaid |
$9,571.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,878.96
|
| Rate for Payer: Managed Health Services Medicaid |
$9,995.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,571.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,571.60
|
| Rate for Payer: United Healthcare Medicaid |
$9,571.60
|
|
|
.DNA Ab (DS) Crithidia Titer
|
Facility
|
OP
|
$14.43
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
6224218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$50.13 |
| Rate for Payer: Aetna Commercial |
$13.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12.91
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna Commercial |
$13.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$13.36
|
| Rate for Payer: HFN Commercial |
$13.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$12.01
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$13.81
|
| Rate for Payer: Quartz Beloit One Network |
$7.35
|
| Rate for Payer: Quartz Commercial |
$9.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$11.26
|
| Rate for Payer: WEA Trust Commercial |
$8.25
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$11.12
|
|
|
.DNA Ab (DS) Crithidia Titer
|
Facility
|
IP
|
$14.43
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
6224218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.35 |
| Max. Negotiated Rate |
$13.81 |
| Rate for Payer: Aetna Commercial |
$13.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7.95
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna Commercial |
$13.81
|
| Rate for Payer: Health EOS Commercial |
$13.36
|
| Rate for Payer: HFN Commercial |
$13.81
|
| Rate for Payer: Multiplan Commercial |
$12.01
|
| Rate for Payer: Preferred Network Access Commercial |
$13.81
|
| Rate for Payer: Quartz Beloit One Network |
$7.35
|
| Rate for Payer: Quartz Commercial |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$8.25
|
| Rate for Payer: WPS Commercial |
$11.12
|
|
|
.DNA Ab (DS) Crithidia Titer
|
Professional
|
Both
|
$14.43
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
6224218
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.60 |
| Max. Negotiated Rate |
$55.14 |
| Rate for Payer: Aetna Commercial |
$14.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12.91
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cash Price |
$4.33
|
| Rate for Payer: Cigna Commercial |
$14.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$13.66
|
| Rate for Payer: HFN Commercial |
$14.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$12.01
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$14.26
|
| Rate for Payer: Quartz Beloit One Network |
$6.60
|
| Rate for Payer: Quartz Commercial |
$8.55
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$8.25
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
DNA Antibody (Double-stranded)
|
Professional
|
Both
|
$280.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
3403540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$276.64 |
| Rate for Payer: Aetna Commercial |
$276.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.43
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$276.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$264.99
|
| Rate for Payer: HFN Commercial |
$276.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$232.96
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| Rate for Payer: Preferred Network Access Commercial |
$276.64
|
| Rate for Payer: Quartz Beloit One Network |
$128.13
|
| Rate for Payer: Quartz Commercial |
$165.98
|
| Rate for Payer: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$56.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: WEA Trust Commercial |
$160.16
|
| Rate for Payer: WPS Commercial |
$62.87
|
|
|
DNA Antibody (Double-stranded)
|
Professional
|
Both
|
$190.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
977928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$187.72 |
| Rate for Payer: Aetna Commercial |
$187.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$187.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$98.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$179.82
|
| Rate for Payer: HFN Commercial |
$187.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| Rate for Payer: Preferred Network Access Commercial |
$187.72
|
| Rate for Payer: Quartz Beloit One Network |
$86.94
|
| Rate for Payer: Quartz Commercial |
$112.63
|
| Rate for Payer: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$56.44
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: WPS Commercial |
$62.87
|
|
|
DNA Antibody (Double-stranded)
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
977928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$181.79 |
| Rate for Payer: Aetna Commercial |
$177.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.72
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$181.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$175.86
|
| Rate for Payer: HFN Commercial |
$181.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| Rate for Payer: Preferred Network Access Commercial |
$181.79
|
| Rate for Payer: Quartz Beloit One Network |
$96.82
|
| Rate for Payer: Quartz Commercial |
$128.44
|
| Rate for Payer: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$57.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: United Healthcare PPO |
$148.20
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: Wellcare Medicare |
$14.29
|
| Rate for Payer: WPS Commercial |
$146.36
|
|
|
DNA Antibody (Double-stranded)
|
Facility
|
IP
|
$280.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
3403540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.69 |
| Max. Negotiated Rate |
$267.90 |
| Rate for Payer: Aetna Commercial |
$262.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.34
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$267.90
|
| Rate for Payer: Health EOS Commercial |
$259.17
|
| Rate for Payer: HFN Commercial |
$267.90
|
| Rate for Payer: Multiplan Commercial |
$232.96
|
| Rate for Payer: Preferred Network Access Commercial |
$267.90
|
| Rate for Payer: Quartz Beloit One Network |
$142.69
|
| Rate for Payer: Quartz Commercial |
$174.72
|
| Rate for Payer: WEA Trust Commercial |
$160.16
|
| Rate for Payer: WPS Commercial |
$215.68
|
|
|
DNA Antibody (Double-stranded)
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
977928
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$96.82 |
| Max. Negotiated Rate |
$181.79 |
| Rate for Payer: Aetna Commercial |
$177.84
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.73
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$181.79
|
| Rate for Payer: Health EOS Commercial |
$175.86
|
| Rate for Payer: HFN Commercial |
$181.79
|
| Rate for Payer: Multiplan Commercial |
$158.08
|
| Rate for Payer: Preferred Network Access Commercial |
$181.79
|
| Rate for Payer: Quartz Beloit One Network |
$96.82
|
| Rate for Payer: Quartz Commercial |
$118.56
|
| Rate for Payer: WEA Trust Commercial |
$108.68
|
| Rate for Payer: WPS Commercial |
$146.36
|
|
|
DNA Antibody (Double-stranded)
|
Facility
|
OP
|
$280.00
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
3403540
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.29 |
| Max. Negotiated Rate |
$267.90 |
| Rate for Payer: Aetna Commercial |
$262.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.43
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.72
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna Commercial |
$267.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.96
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$259.17
|
| Rate for Payer: HFN Commercial |
$267.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.29
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$232.96
|
| Rate for Payer: NAPHCARE Commercial |
$21.43
|
| Rate for Payer: Preferred Network Access Commercial |
$267.90
|
| Rate for Payer: Quartz Beloit One Network |
$142.69
|
| Rate for Payer: Quartz Commercial |
$189.28
|
| Rate for Payer: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$57.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: United Healthcare PPO |
$218.40
|
| Rate for Payer: WEA Trust Commercial |
$160.16
|
| Rate for Payer: Wellcare Medicare |
$14.29
|
| Rate for Payer: WPS Commercial |
$215.68
|
|
|
DNA (ds) Ab, IFA w/ Rfx Titer
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
6179909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
DNA (ds) Ab, IFA w/ Rfx Titer
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
6179909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$50.13 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.99
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.93
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.80
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.94
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$50.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: United Healthcare PPO |
$37.44
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: Wellcare Medicare |
$12.53
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
DNA (ds) Ab, IFA w/ Rfx Titer
|
Professional
|
Both
|
$48.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
6179909
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$55.14 |
| Rate for Payer: Aetna Commercial |
$47.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$12.53
|
| Rate for Payer: Anthem Commercial |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.53
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$47.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.53
|
| Rate for Payer: Health EOS Commercial |
$45.43
|
| Rate for Payer: HFN Commercial |
$47.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.24
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.53
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$18.80
|
| Rate for Payer: Preferred Network Access Commercial |
$47.42
|
| Rate for Payer: Quartz Beloit One Network |
$21.96
|
| Rate for Payer: Quartz Commercial |
$28.45
|
| Rate for Payer: Quartz Medicare Advantage |
$12.53
|
| Rate for Payer: The Alliance Commercial |
$49.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.53
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$55.14
|
|
|
DNase-B Antibody
|
Facility
|
IP
|
$848.00
|
|
|
Service Code
|
CPT 86215
|
| Hospital Charge Code |
1038969
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$432.14 |
| Max. Negotiated Rate |
$811.37 |
| Rate for Payer: Aetna Commercial |
$793.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$758.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$467.42
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cigna Commercial |
$811.37
|
| Rate for Payer: Health EOS Commercial |
$784.91
|
| Rate for Payer: HFN Commercial |
$811.37
|
| Rate for Payer: Multiplan Commercial |
$705.54
|
| Rate for Payer: Preferred Network Access Commercial |
$811.37
|
| Rate for Payer: Quartz Beloit One Network |
$432.14
|
| Rate for Payer: Quartz Commercial |
$529.15
|
| Rate for Payer: WEA Trust Commercial |
$485.06
|
| Rate for Payer: WPS Commercial |
$653.21
|
|
|
DNase-B Antibody
|
Facility
|
OP
|
$848.00
|
|
|
Service Code
|
CPT 86215
|
| Hospital Charge Code |
1038969
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$811.37 |
| Rate for Payer: Aetna Commercial |
$793.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$758.45
|
| Rate for Payer: Aetna Managed Medicare |
$13.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.87
|
| Rate for Payer: Anthem Medicare Advantage |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$467.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.78
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cigna Commercial |
$811.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$493.54
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.78
|
| Rate for Payer: Health EOS Commercial |
$784.91
|
| Rate for Payer: HFN Commercial |
$811.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.78
|
| Rate for Payer: Multiplan Commercial |
$705.54
|
| Rate for Payer: NAPHCARE Commercial |
$20.67
|
| Rate for Payer: Preferred Network Access Commercial |
$811.37
|
| Rate for Payer: Quartz Beloit One Network |
$432.14
|
| Rate for Payer: Quartz Commercial |
$573.25
|
| Rate for Payer: Quartz Medicare Advantage |
$13.78
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.78
|
| Rate for Payer: United Healthcare PPO |
$661.44
|
| Rate for Payer: WEA Trust Commercial |
$485.06
|
| Rate for Payer: Wellcare Medicare |
$13.78
|
| Rate for Payer: WPS Commercial |
$653.21
|
|
