|
EnSnare Kit 6-10mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,831.32 |
| Max. Negotiated Rate |
$3,953.98 |
| Rate for Payer: Aetna Commercial |
$3,953.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,953.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,081.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,497.25
|
| Rate for Payer: Health EOS Commercial |
$3,787.49
|
| Rate for Payer: HFN Commercial |
$3,953.98
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,953.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,831.32
|
| Rate for Payer: Quartz Commercial |
$2,372.39
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit 6-10mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549090
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,165.38 |
| Max. Negotiated Rate |
$3,829.11 |
| Rate for Payer: Aetna Commercial |
$3,745.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,165.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,705.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,081.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,997.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,205.90
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,829.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,329.16
|
| Rate for Payer: Health EOS Commercial |
$3,704.25
|
| Rate for Payer: HFN Commercial |
$3,829.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,121.56
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: NAPHCARE Commercial |
$2,497.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,829.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,039.42
|
| Rate for Payer: Quartz Commercial |
$2,705.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,497.25
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit 9-15mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,165.38 |
| Max. Negotiated Rate |
$3,829.11 |
| Rate for Payer: Aetna Commercial |
$3,745.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,165.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,705.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,081.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,997.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,205.90
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,829.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,329.16
|
| Rate for Payer: Health EOS Commercial |
$3,704.25
|
| Rate for Payer: HFN Commercial |
$3,829.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,121.56
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: NAPHCARE Commercial |
$2,497.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,829.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,039.42
|
| Rate for Payer: Quartz Commercial |
$2,705.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,497.25
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit 9-15mm
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,039.42 |
| Max. Negotiated Rate |
$3,829.11 |
| Rate for Payer: Aetna Commercial |
$3,745.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,205.90
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,829.11
|
| Rate for Payer: Health EOS Commercial |
$3,704.25
|
| Rate for Payer: HFN Commercial |
$3,829.11
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,829.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,039.42
|
| Rate for Payer: Quartz Commercial |
$2,497.25
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit 9-15mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,831.32 |
| Max. Negotiated Rate |
$3,953.98 |
| Rate for Payer: Aetna Commercial |
$3,953.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,953.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,081.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,497.25
|
| Rate for Payer: Health EOS Commercial |
$3,787.49
|
| Rate for Payer: HFN Commercial |
$3,953.98
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,953.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,831.32
|
| Rate for Payer: Quartz Commercial |
$2,372.39
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit mini 4-8mm
|
Facility
|
IP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,039.42 |
| Max. Negotiated Rate |
$3,829.11 |
| Rate for Payer: Aetna Commercial |
$3,745.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,205.90
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,829.11
|
| Rate for Payer: Health EOS Commercial |
$3,704.25
|
| Rate for Payer: HFN Commercial |
$3,829.11
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,829.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,039.42
|
| Rate for Payer: Quartz Commercial |
$2,497.25
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit mini 4-8mm
|
Facility
|
OP
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,165.38 |
| Max. Negotiated Rate |
$3,829.11 |
| Rate for Payer: Aetna Commercial |
$3,745.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Aetna Managed Medicare |
$1,165.38
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,705.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,081.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,997.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,205.90
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,829.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,329.16
|
| Rate for Payer: Health EOS Commercial |
$3,704.25
|
| Rate for Payer: HFN Commercial |
$3,829.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,121.56
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: NAPHCARE Commercial |
$2,497.25
|
| Rate for Payer: Preferred Network Access Commercial |
$3,829.11
|
| Rate for Payer: Quartz Beloit One Network |
$2,039.42
|
| Rate for Payer: Quartz Commercial |
$2,705.35
|
| Rate for Payer: Quartz Medicare Advantage |
$2,497.25
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
EnSnare Kit mini 4-8mm
|
Professional
|
Both
|
$4,002.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
2549088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,831.32 |
| Max. Negotiated Rate |
$3,953.98 |
| Rate for Payer: Aetna Commercial |
$3,953.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,579.39
|
| Rate for Payer: Cash Price |
$1,200.60
|
| Rate for Payer: Cigna Commercial |
$3,953.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,081.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,497.25
|
| Rate for Payer: Health EOS Commercial |
$3,787.49
|
| Rate for Payer: HFN Commercial |
$3,953.98
|
| Rate for Payer: Multiplan Commercial |
$3,329.66
|
| Rate for Payer: Preferred Network Access Commercial |
$3,953.98
|
| Rate for Payer: Quartz Beloit One Network |
$1,831.32
|
| Rate for Payer: Quartz Commercial |
$2,372.39
|
| Rate for Payer: The Alliance Commercial |
$2,081.04
|
| Rate for Payer: WEA Trust Commercial |
$2,289.14
|
| Rate for Payer: WPS Commercial |
$3,082.74
|
|
|
Ensure Clear Nutritional Supplement
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
3031431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Aetna Managed Medicare |
$9.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.21
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.74
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.59
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$22.31
|
| Rate for Payer: Quartz Medicare Advantage |
$20.59
|
| Rate for Payer: The Alliance Commercial |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
Ensure Clear Nutritional Supplement
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
3031431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$20.59
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
Ensure Complete
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
3031432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Ensure Complete
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
3031432
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Ensure - Immune Health
|
Facility
|
IP
|
$10.00
|
|
| Hospital Charge Code |
3031430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Ensure - Immune Health
|
Facility
|
OP
|
$10.00
|
|
| Hospital Charge Code |
3031430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$9.57 |
| Rate for Payer: Aetna Commercial |
$9.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.94
|
| Rate for Payer: Aetna Managed Medicare |
$2.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.51
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.82
|
| Rate for Payer: Health EOS Commercial |
$9.26
|
| Rate for Payer: HFN Commercial |
$9.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.80
|
| Rate for Payer: Multiplan Commercial |
$8.32
|
| Rate for Payer: NAPHCARE Commercial |
$6.24
|
| Rate for Payer: Preferred Network Access Commercial |
$9.57
|
| Rate for Payer: Quartz Beloit One Network |
$5.10
|
| Rate for Payer: Quartz Commercial |
$6.76
|
| Rate for Payer: Quartz Medicare Advantage |
$6.24
|
| Rate for Payer: The Alliance Commercial |
$5.20
|
| Rate for Payer: WEA Trust Commercial |
$5.72
|
| Rate for Payer: WPS Commercial |
$7.70
|
|
|
Ensure Pudding
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
3031433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$5.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5.62
|
| Rate for Payer: The Alliance Commercial |
$4.68
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
Ensure Pudding
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
3031433
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
Entamoeba Histolytica Antibody
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
1039083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$181.42 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$222.14
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Entamoeba Histolytica Antibody
|
Professional
|
Both
|
$356.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
1039083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$351.73 |
| Rate for Payer: Aetna Commercial |
$351.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$12.89
|
| Rate for Payer: Anthem Medicare Advantage |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.89
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$351.73
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.89
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$351.73
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$45.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.89
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$19.33
|
| Rate for Payer: Preferred Network Access Commercial |
$351.73
|
| Rate for Payer: Quartz Beloit One Network |
$162.91
|
| Rate for Payer: Quartz Commercial |
$211.04
|
| Rate for Payer: Quartz Medicare Advantage |
$12.89
|
| Rate for Payer: The Alliance Commercial |
$50.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.89
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: WPS Commercial |
$56.70
|
|
|
Entamoeba Histolytica Antibody
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
1039083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$340.62 |
| Rate for Payer: Aetna Commercial |
$333.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.41
|
| Rate for Payer: Aetna Managed Medicare |
$12.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$48.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.55
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.39
|
| Rate for Payer: Anthem Medicare Advantage |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.89
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cash Price |
$106.80
|
| Rate for Payer: Cigna Commercial |
$340.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.89
|
| Rate for Payer: Health EOS Commercial |
$329.51
|
| Rate for Payer: HFN Commercial |
$340.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.89
|
| Rate for Payer: Multiplan Commercial |
$296.19
|
| Rate for Payer: NAPHCARE Commercial |
$19.33
|
| Rate for Payer: Preferred Network Access Commercial |
$340.62
|
| Rate for Payer: Quartz Beloit One Network |
$181.42
|
| Rate for Payer: Quartz Commercial |
$240.66
|
| Rate for Payer: Quartz Medicare Advantage |
$12.89
|
| Rate for Payer: The Alliance Commercial |
$51.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.89
|
| Rate for Payer: United Healthcare PPO |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$203.63
|
| Rate for Payer: Wellcare Medicare |
$12.89
|
| Rate for Payer: WPS Commercial |
$274.23
|
|
|
Entamoeba Histolytica Antigen
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
CPT 87337
|
| Hospital Charge Code |
4628663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$12.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.68
|
| Rate for Payer: Anthem Medicare Advantage |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.46
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.46
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.46
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.46
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.46
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$18.69
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$12.46
|
| Rate for Payer: The Alliance Commercial |
$49.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.46
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: Wellcare Medicare |
$12.46
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Entamoeba Histolytica Antigen
|
Professional
|
Both
|
$79.00
|
|
|
Service Code
|
CPT 87337
|
| Hospital Charge Code |
4628663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.46 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$12.46
|
| Rate for Payer: Anthem Medicare Advantage |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.46
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.46
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.46
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$18.69
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: Quartz Medicare Advantage |
$12.46
|
| Rate for Payer: The Alliance Commercial |
$49.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.46
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$54.82
|
|
|
Entamoeba Histolytica Antigen
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
CPT 87337
|
| Hospital Charge Code |
4628663
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Enteric Pathogen PCR Panel
|
Facility
|
OP
|
$955.00
|
|
|
Service Code
|
CPT 87506
|
| Hospital Charge Code |
5472874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$273.51 |
| Max. Negotiated Rate |
$1,094.04 |
| Rate for Payer: Aetna Commercial |
$893.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$854.15
|
| Rate for Payer: Aetna Managed Medicare |
$273.51
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,025.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$478.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$454.03
|
| Rate for Payer: Anthem Medicare Advantage |
$273.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$526.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$273.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$273.51
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$913.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$273.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$555.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$273.51
|
| Rate for Payer: Health EOS Commercial |
$883.95
|
| Rate for Payer: HFN Commercial |
$913.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,017.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$273.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$273.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$273.51
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$273.51
|
| Rate for Payer: Multiplan Commercial |
$794.56
|
| Rate for Payer: NAPHCARE Commercial |
$410.26
|
| Rate for Payer: Preferred Network Access Commercial |
$913.74
|
| Rate for Payer: Quartz Beloit One Network |
$486.67
|
| Rate for Payer: Quartz Commercial |
$645.58
|
| Rate for Payer: Quartz Medicare Advantage |
$273.51
|
| Rate for Payer: The Alliance Commercial |
$1,094.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$273.51
|
| Rate for Payer: United Healthcare PPO |
$744.90
|
| Rate for Payer: WEA Trust Commercial |
$546.26
|
| Rate for Payer: Wellcare Medicare |
$273.51
|
| Rate for Payer: WPS Commercial |
$735.64
|
|
|
Enteric Pathogen PCR Panel
|
Professional
|
Both
|
$955.00
|
|
|
Service Code
|
CPT 87506
|
| Hospital Charge Code |
5472874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$273.51 |
| Max. Negotiated Rate |
$1,203.44 |
| Rate for Payer: Aetna Commercial |
$943.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$854.15
|
| Rate for Payer: Aetna Managed Medicare |
$273.51
|
| Rate for Payer: Anthem Medicare Advantage |
$273.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$273.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$273.51
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$943.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$496.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$273.51
|
| Rate for Payer: Health EOS Commercial |
$903.81
|
| Rate for Payer: HFN Commercial |
$943.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$965.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$965.48
|
| Rate for Payer: Independent Care Health Plan Medicare |
$273.51
|
| Rate for Payer: Multiplan Commercial |
$794.56
|
| Rate for Payer: NAPHCARE Commercial |
$410.26
|
| Rate for Payer: Preferred Network Access Commercial |
$943.54
|
| Rate for Payer: Quartz Beloit One Network |
$437.01
|
| Rate for Payer: Quartz Commercial |
$566.12
|
| Rate for Payer: Quartz Medicare Advantage |
$273.51
|
| Rate for Payer: The Alliance Commercial |
$1,080.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$273.51
|
| Rate for Payer: WEA Trust Commercial |
$546.26
|
| Rate for Payer: WPS Commercial |
$1,203.44
|
|
|
Enteric Pathogen PCR Panel
|
Facility
|
IP
|
$955.00
|
|
|
Service Code
|
CPT 87506
|
| Hospital Charge Code |
5472874
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$486.67 |
| Max. Negotiated Rate |
$913.74 |
| Rate for Payer: Aetna Commercial |
$893.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$854.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$526.40
|
| Rate for Payer: Cash Price |
$286.50
|
| Rate for Payer: Cigna Commercial |
$913.74
|
| Rate for Payer: Health EOS Commercial |
$883.95
|
| Rate for Payer: HFN Commercial |
$913.74
|
| Rate for Payer: Multiplan Commercial |
$794.56
|
| Rate for Payer: Preferred Network Access Commercial |
$913.74
|
| Rate for Payer: Quartz Beloit One Network |
$486.67
|
| Rate for Payer: Quartz Commercial |
$595.92
|
| Rate for Payer: WEA Trust Commercial |
$546.26
|
| Rate for Payer: WPS Commercial |
$735.64
|
|
