|
EPO / 100 units (Dialysis)
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3005570
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
EPO / 100 units (Peritoneal Dialysis)
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3026469
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$14.27 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$17.47
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
EPO / 100 units (Peritoneal Dialysis)
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
HCPCS Q4055
|
| Hospital Charge Code |
3026469
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$8.15 |
| Max. Negotiated Rate |
$26.79 |
| Rate for Payer: Aetna Commercial |
$26.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.04
|
| Rate for Payer: Aetna Managed Medicare |
$8.15
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.43
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$25.92
|
| Rate for Payer: HFN Commercial |
$26.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.84
|
| Rate for Payer: Multiplan Commercial |
$23.30
|
| Rate for Payer: NAPHCARE Commercial |
$17.47
|
| Rate for Payer: Preferred Network Access Commercial |
$26.79
|
| Rate for Payer: Quartz Beloit One Network |
$14.27
|
| Rate for Payer: Quartz Commercial |
$18.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.47
|
| Rate for Payer: The Alliance Commercial |
$14.56
|
| Rate for Payer: WEA Trust Commercial |
$16.02
|
| Rate for Payer: WPS Commercial |
$21.57
|
|
|
Epoetin alfa 1000 units ESRD J0886
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3697519
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$30.63 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$0.80
|
| Rate for Payer: Anthem Medicare Advantage |
$0.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.80
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$30.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.86
|
| Rate for Payer: Health EOS Commercial |
$29.34
|
| Rate for Payer: HFN Commercial |
$30.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.80
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$30.63
|
| Rate for Payer: Quartz Beloit One Network |
$14.19
|
| Rate for Payer: Quartz Commercial |
$18.38
|
| Rate for Payer: Quartz Medicare Advantage |
$0.80
|
| Rate for Payer: The Alliance Commercial |
$2.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.80
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Epoetin alfa 1000 units ESRD J0886
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3697519
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$9.03
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.14
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.18
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$19.34
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$19.34
|
| Rate for Payer: The Alliance Commercial |
$3.20
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Epoetin alfa 1000 units ESRD J0886
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
3697519
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Epoetin alfa, non-esrd 1000 U J0885
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
3697520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$8.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.48
|
| Rate for Payer: Anthem Medicare Advantage |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.05
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.05
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$12.07
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$20.96
|
| Rate for Payer: Quartz Medicare Advantage |
$8.05
|
| Rate for Payer: The Alliance Commercial |
$32.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.05
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: Wellcare Medicare |
$8.05
|
| Rate for Payer: WPS Commercial |
$21.51
|
|
|
Epoetin alfa, non-esrd 1000 U J0885
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
3697520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$30.63 |
| Rate for Payer: Aetna Commercial |
$30.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Aetna Managed Medicare |
$8.05
|
| Rate for Payer: Anthem Medicare Advantage |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.05
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$30.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.60
|
| Rate for Payer: Health EOS Commercial |
$29.34
|
| Rate for Payer: HFN Commercial |
$30.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.97
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.05
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: NAPHCARE Commercial |
$12.07
|
| Rate for Payer: Preferred Network Access Commercial |
$30.63
|
| Rate for Payer: Quartz Beloit One Network |
$14.19
|
| Rate for Payer: Quartz Commercial |
$18.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.05
|
| Rate for Payer: The Alliance Commercial |
$22.14
|
| Rate for Payer: United Healthcare Medicaid |
$8.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.05
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$21.51
|
|
|
Epoetin alfa, non-esrd 1000 U J0885
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
3697520
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.80 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna Commercial |
$29.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.09
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$28.69
|
| Rate for Payer: HFN Commercial |
$29.66
|
| Rate for Payer: Multiplan Commercial |
$25.79
|
| Rate for Payer: Preferred Network Access Commercial |
$29.66
|
| Rate for Payer: Quartz Beloit One Network |
$15.80
|
| Rate for Payer: Quartz Commercial |
$19.34
|
| Rate for Payer: WEA Trust Commercial |
$17.73
|
| Rate for Payer: WPS Commercial |
$23.88
|
|
|
Epoetin alfa (Procrit) 100 units ESRD Q4081 (Dialysis)
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
6219845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.14
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.20
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Epoetin alfa (Procrit) 100 units ESRD Q4081 (Dialysis)
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
6219845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Epoetin alfa (Procrit) 100 units ESRD Q4081 (Peritoneal Dialysis)
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
6219846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.14
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.20
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$2.15
|
|
|
Epoetin alfa (Procrit) 100 units ESRD Q4081 (Peritoneal Dialysis)
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS Q4081
|
| Hospital Charge Code |
6219846
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
EPO Supplies (Dialysis)
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3005579
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
EPO Supplies (Dialysis)
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3005579
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
EPO Supplies (Peritoneal Dialysis)
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3026463
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
EPO Supplies (Peritoneal Dialysis)
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3026463
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
EP RV Recording
|
Facility
|
IP
|
$1,132.00
|
|
|
Service Code
|
CPT 93603
|
| Hospital Charge Code |
4125700
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$576.87 |
| Max. Negotiated Rate |
$1,083.10 |
| Rate for Payer: Aetna Commercial |
$1,059.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,012.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$623.96
|
| Rate for Payer: Cash Price |
$339.60
|
| Rate for Payer: Cigna Commercial |
$1,083.10
|
| Rate for Payer: Health EOS Commercial |
$1,047.78
|
| Rate for Payer: HFN Commercial |
$1,083.10
|
| Rate for Payer: Multiplan Commercial |
$941.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,083.10
|
| Rate for Payer: Quartz Beloit One Network |
$576.87
|
| Rate for Payer: Quartz Commercial |
$706.37
|
| Rate for Payer: WEA Trust Commercial |
$647.50
|
| Rate for Payer: WPS Commercial |
$871.98
|
|
|
EP RV Recording
|
Facility
|
OP
|
$1,132.00
|
|
|
Service Code
|
CPT 93603
|
| Hospital Charge Code |
4125700
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$576.87 |
| Max. Negotiated Rate |
$30,304.56 |
| Rate for Payer: Aetna Commercial |
$1,059.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,012.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,281.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,304.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27,476.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26,104.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,281.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$623.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,281.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,281.32
|
| Rate for Payer: Cash Price |
$339.60
|
| Rate for Payer: Cash Price |
$339.60
|
| Rate for Payer: Cash Price |
$339.60
|
| Rate for Payer: Cigna Commercial |
$1,083.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,281.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$658.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,281.32
|
| Rate for Payer: Health EOS Commercial |
$1,047.78
|
| Rate for Payer: HFN Commercial |
$1,083.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,766.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,281.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,281.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,281.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,281.32
|
| Rate for Payer: Multiplan Commercial |
$941.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,921.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,083.10
|
| Rate for Payer: Quartz Beloit One Network |
$576.87
|
| Rate for Payer: Quartz Commercial |
$765.23
|
| Rate for Payer: Quartz Medicare Advantage |
$1,281.32
|
| Rate for Payer: The Alliance Commercial |
$5,125.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,281.32
|
| Rate for Payer: WEA Trust Commercial |
$647.50
|
| Rate for Payer: Wellcare Medicare |
$1,281.32
|
| Rate for Payer: WPS Commercial |
$871.98
|
|
|
Epstein Barr Early Antigen Detection
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
Epstein Barr Early Antigen Detection
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$13.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.65
|
| Rate for Payer: Anthem Medicare Advantage |
$13.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.64
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.64
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.64
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$20.47
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$13.64
|
| Rate for Payer: The Alliance Commercial |
$54.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.64
|
| Rate for Payer: United Healthcare PPO |
$63.18
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: Wellcare Medicare |
$13.64
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
Epstein Barr Early Antigen Detection
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.64 |
| Max. Negotiated Rate |
$80.03 |
| Rate for Payer: Aetna Commercial |
$80.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$13.64
|
| Rate for Payer: Anthem Medicare Advantage |
$13.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.64
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$80.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$42.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.64
|
| Rate for Payer: Health EOS Commercial |
$76.66
|
| Rate for Payer: HFN Commercial |
$80.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.64
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$20.47
|
| Rate for Payer: Preferred Network Access Commercial |
$80.03
|
| Rate for Payer: Quartz Beloit One Network |
$37.07
|
| Rate for Payer: Quartz Commercial |
$48.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13.64
|
| Rate for Payer: The Alliance Commercial |
$53.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.64
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$60.04
|
|
|
Epstein Barr Nuclear Antibody
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$136.57 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$167.23
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
|
Epstein Barr Nuclear Antibody
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$264.78 |
| Rate for Payer: Aetna Commercial |
$264.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Aetna Managed Medicare |
$15.90
|
| Rate for Payer: Anthem Medicare Advantage |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.90
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$264.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.90
|
| Rate for Payer: Health EOS Commercial |
$253.64
|
| Rate for Payer: HFN Commercial |
$264.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.90
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: NAPHCARE Commercial |
$23.85
|
| Rate for Payer: Preferred Network Access Commercial |
$264.78
|
| Rate for Payer: Quartz Beloit One Network |
$122.64
|
| Rate for Payer: Quartz Commercial |
$158.87
|
| Rate for Payer: Quartz Medicare Advantage |
$15.90
|
| Rate for Payer: The Alliance Commercial |
$62.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.90
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: WPS Commercial |
$69.97
|
|
|
Epstein Barr Nuclear Antibody
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$256.42 |
| Rate for Payer: Aetna Commercial |
$250.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.70
|
| Rate for Payer: Aetna Managed Medicare |
$15.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.40
|
| Rate for Payer: Anthem Medicare Advantage |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.90
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$256.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$155.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.90
|
| Rate for Payer: Health EOS Commercial |
$248.06
|
| Rate for Payer: HFN Commercial |
$256.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.90
|
| Rate for Payer: Multiplan Commercial |
$222.98
|
| Rate for Payer: NAPHCARE Commercial |
$23.85
|
| Rate for Payer: Preferred Network Access Commercial |
$256.42
|
| Rate for Payer: Quartz Beloit One Network |
$136.57
|
| Rate for Payer: Quartz Commercial |
$181.17
|
| Rate for Payer: Quartz Medicare Advantage |
$15.90
|
| Rate for Payer: The Alliance Commercial |
$63.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.90
|
| Rate for Payer: United Healthcare PPO |
$209.04
|
| Rate for Payer: WEA Trust Commercial |
$153.30
|
| Rate for Payer: Wellcare Medicare |
$15.90
|
| Rate for Payer: WPS Commercial |
$206.44
|
|
