|
Ethanol Level
|
Facility
|
OP
|
$337.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
1037117
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.13 |
| Max. Negotiated Rate |
$322.44 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Aetna Managed Medicare |
$98.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$227.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$175.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$168.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$196.13
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$262.86
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: NAPHCARE Commercial |
$210.29
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$227.81
|
| Rate for Payer: Quartz Medicare Advantage |
$210.29
|
| Rate for Payer: The Alliance Commercial |
$175.24
|
| Rate for Payer: United Healthcare PPO |
$262.86
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Ethanol Level
|
Facility
|
IP
|
$337.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
1037117
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$171.74 |
| Max. Negotiated Rate |
$322.44 |
| Rate for Payer: Aetna Commercial |
$315.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$301.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$185.75
|
| Rate for Payer: Cash Price |
$101.10
|
| Rate for Payer: Cigna Commercial |
$322.44
|
| Rate for Payer: Health EOS Commercial |
$311.93
|
| Rate for Payer: HFN Commercial |
$322.44
|
| Rate for Payer: Multiplan Commercial |
$280.38
|
| Rate for Payer: Preferred Network Access Commercial |
$322.44
|
| Rate for Payer: Quartz Beloit One Network |
$171.74
|
| Rate for Payer: Quartz Commercial |
$210.29
|
| Rate for Payer: WEA Trust Commercial |
$192.76
|
| Rate for Payer: WPS Commercial |
$259.59
|
|
|
Ethanol Level
|
Facility
|
OP
|
$349.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
633725
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$101.63 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Aetna Managed Medicare |
$101.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$181.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$174.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.12
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$272.22
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: NAPHCARE Commercial |
$217.78
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$235.92
|
| Rate for Payer: Quartz Medicare Advantage |
$217.78
|
| Rate for Payer: The Alliance Commercial |
$181.48
|
| Rate for Payer: United Healthcare PPO |
$272.22
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Ethanol Level
|
Professional
|
Both
|
$349.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
633725
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$344.81 |
| Rate for Payer: Aetna Commercial |
$344.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$344.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$181.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$217.78
|
| Rate for Payer: Health EOS Commercial |
$330.29
|
| Rate for Payer: HFN Commercial |
$344.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$344.81
|
| Rate for Payer: Quartz Beloit One Network |
$159.70
|
| Rate for Payer: Quartz Commercial |
$206.89
|
| Rate for Payer: The Alliance Commercial |
$181.48
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Ethanol Level
|
Facility
|
IP
|
$349.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
633725
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$177.85 |
| Max. Negotiated Rate |
$333.92 |
| Rate for Payer: Aetna Commercial |
$326.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$312.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.37
|
| Rate for Payer: Cash Price |
$104.70
|
| Rate for Payer: Cigna Commercial |
$333.92
|
| Rate for Payer: Health EOS Commercial |
$323.03
|
| Rate for Payer: HFN Commercial |
$333.92
|
| Rate for Payer: Multiplan Commercial |
$290.37
|
| Rate for Payer: Preferred Network Access Commercial |
$333.92
|
| Rate for Payer: Quartz Beloit One Network |
$177.85
|
| Rate for Payer: Quartz Commercial |
$217.78
|
| Rate for Payer: WEA Trust Commercial |
$199.63
|
| Rate for Payer: WPS Commercial |
$268.83
|
|
|
Ethanol Level (Tox Scr)
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
4494624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$182.44 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$223.39
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Ethanol Level (Tox Scr)
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
4494624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.25 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Aetna Managed Medicare |
$104.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$186.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$178.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$208.36
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$279.24
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: NAPHCARE Commercial |
$223.39
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$242.01
|
| Rate for Payer: Quartz Medicare Advantage |
$223.39
|
| Rate for Payer: The Alliance Commercial |
$186.16
|
| Rate for Payer: United Healthcare PPO |
$279.24
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Ethanol Level (Tox Scr)
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
4494624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$353.70 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$353.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$186.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$223.39
|
| Rate for Payer: Health EOS Commercial |
$338.81
|
| Rate for Payer: HFN Commercial |
$353.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: Preferred Network Access Commercial |
$353.70
|
| Rate for Payer: Quartz Beloit One Network |
$163.82
|
| Rate for Payer: Quartz Commercial |
$212.22
|
| Rate for Payer: The Alliance Commercial |
$186.16
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Ethosuximide Level
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.44 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Aetna Managed Medicare |
$114.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$265.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$204.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$196.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$228.73
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$306.54
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: NAPHCARE Commercial |
$245.23
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$265.67
|
| Rate for Payer: Quartz Medicare Advantage |
$245.23
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: United Healthcare PPO |
$306.54
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
Ethosuximide Level
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$388.28 |
| Rate for Payer: Aetna Commercial |
$388.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$388.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$204.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$245.23
|
| Rate for Payer: Health EOS Commercial |
$371.94
|
| Rate for Payer: HFN Commercial |
$388.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$388.28
|
| Rate for Payer: Quartz Beloit One Network |
$179.84
|
| Rate for Payer: Quartz Commercial |
$232.97
|
| Rate for Payer: The Alliance Commercial |
$204.36
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
Ethosuximide Level
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$200.27 |
| Max. Negotiated Rate |
$376.02 |
| Rate for Payer: Aetna Commercial |
$367.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$351.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$216.62
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$376.02
|
| Rate for Payer: Health EOS Commercial |
$363.76
|
| Rate for Payer: HFN Commercial |
$376.02
|
| Rate for Payer: Multiplan Commercial |
$326.98
|
| Rate for Payer: Preferred Network Access Commercial |
$376.02
|
| Rate for Payer: Quartz Beloit One Network |
$200.27
|
| Rate for Payer: Quartz Commercial |
$245.23
|
| Rate for Payer: WEA Trust Commercial |
$224.80
|
| Rate for Payer: WPS Commercial |
$302.73
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$286.40 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.77
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$537.72
|
| Rate for Payer: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$350.69
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$537.72 |
| Rate for Payer: Aetna Commercial |
$526.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| Rate for Payer: Aetna Managed Medicare |
$15.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.72
|
| Rate for Payer: Anthem Medicare Advantage |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$309.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.50
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$537.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$327.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.50
|
| Rate for Payer: Health EOS Commercial |
$520.19
|
| Rate for Payer: HFN Commercial |
$537.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.50
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: NAPHCARE Commercial |
$23.24
|
| Rate for Payer: Preferred Network Access Commercial |
$537.72
|
| Rate for Payer: Quartz Beloit One Network |
$286.40
|
| Rate for Payer: Quartz Commercial |
$379.91
|
| Rate for Payer: Quartz Medicare Advantage |
$15.50
|
| Rate for Payer: The Alliance Commercial |
$61.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.50
|
| Rate for Payer: United Healthcare PPO |
$438.36
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: Wellcare Medicare |
$15.50
|
| Rate for Payer: WPS Commercial |
$432.91
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$555.26 |
| Rate for Payer: Aetna Commercial |
$555.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$502.65
|
| Rate for Payer: Aetna Managed Medicare |
$15.50
|
| Rate for Payer: Anthem Medicare Advantage |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.50
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$555.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$292.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.50
|
| Rate for Payer: Health EOS Commercial |
$531.88
|
| Rate for Payer: HFN Commercial |
$555.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.50
|
| Rate for Payer: Multiplan Commercial |
$467.58
|
| Rate for Payer: NAPHCARE Commercial |
$23.24
|
| Rate for Payer: Preferred Network Access Commercial |
$555.26
|
| Rate for Payer: Quartz Beloit One Network |
$257.17
|
| Rate for Payer: Quartz Commercial |
$333.15
|
| Rate for Payer: Quartz Medicare Advantage |
$15.50
|
| Rate for Payer: The Alliance Commercial |
$61.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.50
|
| Rate for Payer: WEA Trust Commercial |
$321.46
|
| Rate for Payer: WPS Commercial |
$68.18
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$275.18 |
| Max. Negotiated Rate |
$516.67 |
| Rate for Payer: Aetna Commercial |
$505.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.65
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$516.67
|
| Rate for Payer: Health EOS Commercial |
$499.82
|
| Rate for Payer: HFN Commercial |
$516.67
|
| Rate for Payer: Multiplan Commercial |
$449.28
|
| Rate for Payer: Preferred Network Access Commercial |
$516.67
|
| Rate for Payer: Quartz Beloit One Network |
$275.18
|
| Rate for Payer: Quartz Commercial |
$336.96
|
| Rate for Payer: WEA Trust Commercial |
$308.88
|
| Rate for Payer: WPS Commercial |
$415.96
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$516.67 |
| Rate for Payer: Aetna Commercial |
$505.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.98
|
| Rate for Payer: Aetna Managed Medicare |
$15.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.11
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.72
|
| Rate for Payer: Anthem Medicare Advantage |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.50
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$516.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$314.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.50
|
| Rate for Payer: Health EOS Commercial |
$499.82
|
| Rate for Payer: HFN Commercial |
$516.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.50
|
| Rate for Payer: Multiplan Commercial |
$449.28
|
| Rate for Payer: NAPHCARE Commercial |
$23.24
|
| Rate for Payer: Preferred Network Access Commercial |
$516.67
|
| Rate for Payer: Quartz Beloit One Network |
$275.18
|
| Rate for Payer: Quartz Commercial |
$365.04
|
| Rate for Payer: Quartz Medicare Advantage |
$15.50
|
| Rate for Payer: The Alliance Commercial |
$61.98
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.50
|
| Rate for Payer: United Healthcare PPO |
$421.20
|
| Rate for Payer: WEA Trust Commercial |
$308.88
|
| Rate for Payer: Wellcare Medicare |
$15.50
|
| Rate for Payer: WPS Commercial |
$415.96
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Professional
|
Both
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$533.52 |
| Rate for Payer: Aetna Commercial |
$533.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$482.98
|
| Rate for Payer: Aetna Managed Medicare |
$15.50
|
| Rate for Payer: Anthem Medicare Advantage |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.50
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$533.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$280.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.50
|
| Rate for Payer: Health EOS Commercial |
$511.06
|
| Rate for Payer: HFN Commercial |
$533.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.70
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.50
|
| Rate for Payer: Multiplan Commercial |
$449.28
|
| Rate for Payer: NAPHCARE Commercial |
$23.24
|
| Rate for Payer: Preferred Network Access Commercial |
$533.52
|
| Rate for Payer: Quartz Beloit One Network |
$247.10
|
| Rate for Payer: Quartz Commercial |
$320.11
|
| Rate for Payer: Quartz Medicare Advantage |
$15.50
|
| Rate for Payer: The Alliance Commercial |
$61.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.50
|
| Rate for Payer: WEA Trust Commercial |
$308.88
|
| Rate for Payer: WPS Commercial |
$68.18
|
|
|
ET intubation - Resuscitation at Birth:
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
3000343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$100.17 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Aetna Managed Medicare |
$100.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$178.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.21
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.32
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: NAPHCARE Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$232.54
|
| Rate for Payer: Quartz Medicare Advantage |
$214.66
|
| Rate for Payer: The Alliance Commercial |
$178.88
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
ET intubation - Resuscitation at Birth:
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
3000343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$175.30 |
| Max. Negotiated Rate |
$329.14 |
| Rate for Payer: Aetna Commercial |
$321.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.61
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$329.14
|
| Rate for Payer: Health EOS Commercial |
$318.41
|
| Rate for Payer: HFN Commercial |
$329.14
|
| Rate for Payer: Multiplan Commercial |
$286.21
|
| Rate for Payer: Preferred Network Access Commercial |
$329.14
|
| Rate for Payer: Quartz Beloit One Network |
$175.30
|
| Rate for Payer: Quartz Commercial |
$214.66
|
| Rate for Payer: WEA Trust Commercial |
$196.77
|
| Rate for Payer: WPS Commercial |
$264.98
|
|
|
Etonogestrel implant system J7307 man
|
Facility
|
IP
|
$1,929.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
3373607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$983.02 |
| Max. Negotiated Rate |
$1,845.67 |
| Rate for Payer: Aetna Commercial |
$1,805.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,725.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.26
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,845.67
|
| Rate for Payer: Health EOS Commercial |
$1,785.48
|
| Rate for Payer: HFN Commercial |
$1,845.67
|
| Rate for Payer: Multiplan Commercial |
$1,604.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,845.67
|
| Rate for Payer: Quartz Beloit One Network |
$983.02
|
| Rate for Payer: Quartz Commercial |
$1,203.70
|
| Rate for Payer: WEA Trust Commercial |
$1,103.39
|
| Rate for Payer: WPS Commercial |
$1,485.91
|
|
|
Etonogestrel implant system J7307 man
|
Professional
|
Both
|
$1,929.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
3373607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$882.71 |
| Max. Negotiated Rate |
$1,905.85 |
| Rate for Payer: Aetna Commercial |
$1,905.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,725.30
|
| Rate for Payer: Anthem Commercial |
$1,020.82
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,905.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,326.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,203.70
|
| Rate for Payer: Health EOS Commercial |
$1,825.61
|
| Rate for Payer: HFN Commercial |
$1,905.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,527.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,527.67
|
| Rate for Payer: Multiplan Commercial |
$1,604.93
|
| Rate for Payer: Preferred Network Access Commercial |
$1,905.85
|
| Rate for Payer: Quartz Beloit One Network |
$882.71
|
| Rate for Payer: Quartz Commercial |
$1,143.51
|
| Rate for Payer: The Alliance Commercial |
$1,003.08
|
| Rate for Payer: United Healthcare Medicaid |
$1,326.37
|
| Rate for Payer: WEA Trust Commercial |
$1,103.39
|
| Rate for Payer: WPS Commercial |
$1,485.91
|
|
|
Etonogestrel implant system J7307 man
|
Facility
|
OP
|
$1,929.00
|
|
|
Service Code
|
HCPCS J7307
|
| Hospital Charge Code |
3373607
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$561.72 |
| Max. Negotiated Rate |
$1,845.67 |
| Rate for Payer: Aetna Commercial |
$1,805.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,725.30
|
| Rate for Payer: Aetna Managed Medicare |
$561.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,304.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,003.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$962.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,063.26
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,845.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,122.68
|
| Rate for Payer: Health EOS Commercial |
$1,785.48
|
| Rate for Payer: HFN Commercial |
$1,845.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,504.62
|
| Rate for Payer: Multiplan Commercial |
$1,604.93
|
| Rate for Payer: NAPHCARE Commercial |
$1,203.70
|
| Rate for Payer: Preferred Network Access Commercial |
$1,845.67
|
| Rate for Payer: Quartz Beloit One Network |
$983.02
|
| Rate for Payer: Quartz Commercial |
$1,304.00
|
| Rate for Payer: Quartz Medicare Advantage |
$1,203.70
|
| Rate for Payer: The Alliance Commercial |
$1,003.08
|
| Rate for Payer: WEA Trust Commercial |
$1,103.39
|
| Rate for Payer: WPS Commercial |
$1,485.91
|
|
|
E.T. Tube 2.0 - 8.0
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3149564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Aetna Managed Medicare |
$0.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.75
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.34
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: NAPHCARE Commercial |
$1.87
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$2.03
|
| Rate for Payer: Quartz Medicare Advantage |
$1.87
|
| Rate for Payer: The Alliance Commercial |
$1.56
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
E.T. Tube 2.0 - 8.0
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3149564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.65
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.87
|
| Rate for Payer: Health EOS Commercial |
$2.78
|
| Rate for Payer: HFN Commercial |
$2.87
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$2.87
|
| Rate for Payer: Quartz Beloit One Network |
$1.53
|
| Rate for Payer: Quartz Commercial |
$1.87
|
| Rate for Payer: WEA Trust Commercial |
$1.72
|
| Rate for Payer: WPS Commercial |
$2.31
|
|
|
Euflexxa 1 Unit = 1 Unit Charge
|
Professional
|
Both
|
$2,615.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
5386676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.68 |
| Max. Negotiated Rate |
$2,583.62 |
| Rate for Payer: Aetna Commercial |
$2,583.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,338.86
|
| Rate for Payer: Aetna Managed Medicare |
$109.68
|
| Rate for Payer: Anthem Medicare Advantage |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$109.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$109.68
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,583.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$109.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$120.20
|
| Rate for Payer: Health EOS Commercial |
$2,474.84
|
| Rate for Payer: HFN Commercial |
$2,583.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$109.68
|
| Rate for Payer: Multiplan Commercial |
$2,175.68
|
| Rate for Payer: NAPHCARE Commercial |
$164.52
|
| Rate for Payer: Preferred Network Access Commercial |
$2,583.62
|
| Rate for Payer: Quartz Beloit One Network |
$1,196.62
|
| Rate for Payer: Quartz Commercial |
$1,550.17
|
| Rate for Payer: Quartz Medicare Advantage |
$109.68
|
| Rate for Payer: The Alliance Commercial |
$301.62
|
| Rate for Payer: United Healthcare Medicaid |
$109.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$109.68
|
| Rate for Payer: WEA Trust Commercial |
$1,495.78
|
| Rate for Payer: WPS Commercial |
$300.49
|
|
