|
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 |
$1.09 |
| Max. Negotiated Rate |
$124.00 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.25
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$18.60
|
| Rate for Payer: The Alliance Commercial |
$124.00
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
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 |
$0.83 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Aetna Commercial |
$29.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.83
|
| Rate for Payer: Health EOS Commercial |
$28.21
|
| Rate for Payer: HFN Commercial |
$29.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: Preferred Network Access Commercial |
$29.45
|
| Rate for Payer: Quartz Beloit One Network |
$13.64
|
| Rate for Payer: Quartz Commercial |
$17.67
|
| Rate for Payer: The Alliance Commercial |
$15.50
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
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 |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
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 |
$8.27 |
| Max. Negotiated Rate |
$29.45 |
| Rate for Payer: Aetna Commercial |
$29.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$29.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.27
|
| Rate for Payer: Health EOS Commercial |
$28.21
|
| Rate for Payer: HFN Commercial |
$29.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.47
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: Preferred Network Access Commercial |
$29.45
|
| Rate for Payer: Quartz Beloit One Network |
$13.64
|
| Rate for Payer: Quartz Commercial |
$17.67
|
| Rate for Payer: The Alliance Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicaid |
$8.27
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$20.68
|
|
|
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 |
$15.19 |
| Max. Negotiated Rate |
$28.52 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$18.60
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: WPS Commercial |
$22.96
|
|
|
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 |
$8.89 |
| Max. Negotiated Rate |
$35.54 |
| Rate for Payer: Aetna Commercial |
$27.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.66
|
| Rate for Payer: Aetna Managed Medicare |
$8.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.89
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cash Price |
$9.30
|
| Rate for Payer: Cigna Commercial |
$28.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.89
|
| Rate for Payer: Health EOS Commercial |
$27.59
|
| Rate for Payer: HFN Commercial |
$28.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.89
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.89
|
| Rate for Payer: Multiplan Commercial |
$24.80
|
| Rate for Payer: NAPHCARE Commercial |
$13.33
|
| Rate for Payer: Preferred Network Access Commercial |
$28.52
|
| Rate for Payer: Quartz Beloit One Network |
$15.19
|
| Rate for Payer: Quartz Commercial |
$20.15
|
| Rate for Payer: Quartz Medicare Advantage |
$8.89
|
| Rate for Payer: The Alliance Commercial |
$35.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.89
|
| Rate for Payer: WEA Trust Commercial |
$17.05
|
| Rate for Payer: Wellcare Medicare |
$8.89
|
| Rate for Payer: WPS Commercial |
$20.68
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
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 |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
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 |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
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 |
$1.09 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$2.07
|
|
|
EPO Supplies (Dialysis)
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3005579
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
EPO Supplies (Dialysis)
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3005579
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
EPO Supplies (Peritoneal Dialysis)
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3026463
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
EPO Supplies (Peritoneal Dialysis)
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3026463
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
EP RV Recording
|
Facility
|
IP
|
$1,132.00
|
|
|
Service Code
|
CPT 93603
|
| Hospital Charge Code |
4125700
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$554.68 |
| Max. Negotiated Rate |
$1,041.44 |
| Rate for Payer: Aetna Commercial |
$1,018.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$973.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$599.96
|
| Rate for Payer: Cash Price |
$339.60
|
| Rate for Payer: Cigna Commercial |
$1,041.44
|
| Rate for Payer: Health EOS Commercial |
$1,007.48
|
| Rate for Payer: HFN Commercial |
$1,041.44
|
| Rate for Payer: Multiplan Commercial |
$905.60
|
| Rate for Payer: NAPHCARE Commercial |
$679.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,041.44
|
| Rate for Payer: Quartz Beloit One Network |
$554.68
|
| Rate for Payer: Quartz Commercial |
$679.20
|
| Rate for Payer: WEA Trust Commercial |
$622.60
|
| Rate for Payer: WPS Commercial |
$838.47
|
|
|
EP RV Recording
|
Facility
|
OP
|
$1,132.00
|
|
|
Service Code
|
CPT 93603
|
| Hospital Charge Code |
4125700
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$554.68 |
| Max. Negotiated Rate |
$29,139.00 |
| Rate for Payer: Aetna Commercial |
$1,018.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$973.52
|
| Rate for Payer: Aetna Managed Medicare |
$1,176.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29,139.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,420.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25,100.00
|
| Rate for Payer: Anthem Medicare Advantage |
$1,176.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$599.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,176.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,176.34
|
| 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 |
$1,041.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,176.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$633.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,176.34
|
| Rate for Payer: Health EOS Commercial |
$1,007.48
|
| Rate for Payer: HFN Commercial |
$1,041.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,375.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,176.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,176.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,176.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,176.34
|
| Rate for Payer: Multiplan Commercial |
$905.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,764.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,041.44
|
| Rate for Payer: Quartz Beloit One Network |
$554.68
|
| Rate for Payer: Quartz Commercial |
$735.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,176.34
|
| Rate for Payer: The Alliance Commercial |
$4,705.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,176.34
|
| Rate for Payer: WEA Trust Commercial |
$622.60
|
| Rate for Payer: Wellcare Medicare |
$1,176.34
|
| Rate for Payer: WPS Commercial |
$838.47
|
|
|
Epstein Barr Early Antigen Detection
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Aetna Managed Medicare |
$13.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.78
|
| Rate for Payer: Anthem Medicaid |
$13.56
|
| Rate for Payer: Anthem Medicare Advantage |
$13.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.12
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.33
|
| Rate for Payer: Dean Health Medicaid |
$13.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.12
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.12
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.56
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.12
|
| Rate for Payer: Managed Health Services Medicaid |
$14.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.12
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$19.68
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.56
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$52.65
|
| Rate for Payer: Quartz Medicare Advantage |
$13.12
|
| Rate for Payer: The Alliance Commercial |
$52.48
|
| Rate for Payer: United Healthcare Medicaid |
$13.56
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.12
|
| Rate for Payer: United Healthcare PPO |
$60.75
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: Wellcare Medicare |
$13.12
|
| Rate for Payer: WMAP Medicaid |
$13.56
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Epstein Barr Early Antigen Detection
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.69 |
| Max. Negotiated Rate |
$74.52 |
| Rate for Payer: Aetna Commercial |
$72.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.93
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$74.52
|
| Rate for Payer: Health EOS Commercial |
$72.09
|
| Rate for Payer: HFN Commercial |
$74.52
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: NAPHCARE Commercial |
$48.60
|
| Rate for Payer: Preferred Network Access Commercial |
$74.52
|
| Rate for Payer: Quartz Beloit One Network |
$39.69
|
| Rate for Payer: Quartz Commercial |
$48.60
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Epstein Barr Early Antigen Detection
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
CPT 86663
|
| Hospital Charge Code |
5176624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.64 |
| Max. Negotiated Rate |
$76.95 |
| Rate for Payer: Aetna Commercial |
$76.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.66
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$76.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$40.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.60
|
| Rate for Payer: Health EOS Commercial |
$73.71
|
| Rate for Payer: HFN Commercial |
$76.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.31
|
| Rate for Payer: Multiplan Commercial |
$64.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.95
|
| Rate for Payer: Quartz Beloit One Network |
$35.64
|
| Rate for Payer: Quartz Commercial |
$46.17
|
| Rate for Payer: The Alliance Commercial |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$44.55
|
| Rate for Payer: WPS Commercial |
$60.00
|
|
|
Epstein Barr Nuclear Antibody
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$131.32 |
| Max. Negotiated Rate |
$246.56 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$160.80
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$160.80
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
Epstein Barr Nuclear Antibody
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.97 |
| Max. Negotiated Rate |
$254.60 |
| Rate for Payer: Aetna Commercial |
$254.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$254.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.80
|
| Rate for Payer: Health EOS Commercial |
$243.88
|
| Rate for Payer: HFN Commercial |
$254.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$53.97
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: Preferred Network Access Commercial |
$254.60
|
| Rate for Payer: Quartz Beloit One Network |
$117.92
|
| Rate for Payer: Quartz Commercial |
$152.76
|
| Rate for Payer: The Alliance Commercial |
$134.00
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
Epstein Barr Nuclear Antibody
|
Facility
|
OP
|
$268.00
|
|
|
Service Code
|
CPT 86664
|
| Hospital Charge Code |
977935
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$246.56 |
| Rate for Payer: Aetna Commercial |
$241.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.48
|
| Rate for Payer: Aetna Managed Medicare |
$15.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$57.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.38
|
| Rate for Payer: Anthem Medicaid |
$15.80
|
| Rate for Payer: Anthem Medicare Advantage |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.29
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cash Price |
$80.40
|
| Rate for Payer: Cigna Commercial |
$246.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$149.97
|
| Rate for Payer: Dean Health Medicaid |
$15.80
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15.29
|
| Rate for Payer: Health EOS Commercial |
$238.52
|
| Rate for Payer: HFN Commercial |
$246.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.80
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.29
|
| Rate for Payer: Managed Health Services Medicaid |
$16.43
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15.29
|
| Rate for Payer: Multiplan Commercial |
$214.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.94
|
| Rate for Payer: Preferred Network Access Commercial |
$246.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.80
|
| Rate for Payer: Quartz Beloit One Network |
$131.32
|
| Rate for Payer: Quartz Commercial |
$174.20
|
| Rate for Payer: Quartz Medicare Advantage |
$15.29
|
| Rate for Payer: The Alliance Commercial |
$61.16
|
| Rate for Payer: United Healthcare Medicaid |
$15.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.29
|
| Rate for Payer: United Healthcare PPO |
$201.00
|
| Rate for Payer: WEA Trust Commercial |
$147.40
|
| Rate for Payer: Wellcare Medicare |
$15.29
|
| Rate for Payer: WMAP Medicaid |
$15.80
|
| Rate for Payer: WPS Commercial |
$198.51
|
|
|
Epstein-Barr Viral Capsid Antigen (VCA) Antibody (IgA)
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
5569256
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.34 |
| Max. Negotiated Rate |
$60.72 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$39.60
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$39.60
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Epstein-Barr Viral Capsid Antigen (VCA) Antibody (IgA)
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
5569256
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$72.56 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Aetna Managed Medicare |
$18.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$68.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.11
|
| Rate for Payer: Anthem Medicaid |
$18.74
|
| Rate for Payer: Anthem Medicare Advantage |
$18.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.14
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.93
|
| Rate for Payer: Dean Health Medicaid |
$18.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.14
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.48
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.14
|
| Rate for Payer: Managed Health Services Medicaid |
$19.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.14
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.21
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18.74
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$42.90
|
| Rate for Payer: Quartz Medicare Advantage |
$18.14
|
| Rate for Payer: The Alliance Commercial |
$72.56
|
| Rate for Payer: United Healthcare Medicaid |
$18.74
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.14
|
| Rate for Payer: United Healthcare PPO |
$49.50
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: Wellcare Medicare |
$18.14
|
| Rate for Payer: WMAP Medicaid |
$18.74
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Epstein-Barr Viral Capsid Antigen (VCA) Antibody (IgA)
|
Professional
|
Both
|
$66.00
|
|
|
Service Code
|
CPT 86665
|
| Hospital Charge Code |
5569256
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$64.03 |
| Rate for Payer: Aetna Commercial |
$62.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$62.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.60
|
| Rate for Payer: Health EOS Commercial |
$60.06
|
| Rate for Payer: HFN Commercial |
$62.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.03
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: Preferred Network Access Commercial |
$62.70
|
| Rate for Payer: Quartz Beloit One Network |
$29.04
|
| Rate for Payer: Quartz Commercial |
$37.62
|
| Rate for Payer: The Alliance Commercial |
$33.00
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
