|
Ethanol Level (Tox Scr)
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
4494624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.24 |
| Max. Negotiated Rate |
$1,432.00 |
| Rate for Payer: Aetna Commercial |
$322.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Aetna Managed Medicare |
$100.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$232.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$179.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$171.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.74
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$329.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.34
|
| Rate for Payer: Health EOS Commercial |
$318.62
|
| Rate for Payer: HFN Commercial |
$329.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.50
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: NAPHCARE Commercial |
$214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$329.36
|
| Rate for Payer: Quartz Beloit One Network |
$175.42
|
| Rate for Payer: Quartz Commercial |
$232.70
|
| Rate for Payer: Quartz Medicare Advantage |
$214.80
|
| Rate for Payer: The Alliance Commercial |
$1,432.00
|
| Rate for Payer: United Healthcare PPO |
$268.50
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Ethanol Level (Tox Scr)
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
4494624
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$340.10 |
| Rate for Payer: Aetna Commercial |
$340.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$340.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$179.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.80
|
| Rate for Payer: Health EOS Commercial |
$325.78
|
| Rate for Payer: HFN Commercial |
$340.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: Preferred Network Access Commercial |
$340.10
|
| Rate for Payer: Quartz Beloit One Network |
$157.52
|
| Rate for Payer: Quartz Commercial |
$204.06
|
| Rate for Payer: The Alliance Commercial |
$179.00
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Ethosuximide Level
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.04 |
| Max. Negotiated Rate |
$1,572.00 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Aetna Managed Medicare |
$110.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$255.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$196.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$188.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$219.92
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$294.75
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$255.45
|
| Rate for Payer: Quartz Medicare Advantage |
$235.80
|
| Rate for Payer: The Alliance Commercial |
$1,572.00
|
| Rate for Payer: United Healthcare PPO |
$294.75
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
Ethosuximide Level
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$373.35 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$196.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$235.80
|
| Rate for Payer: Health EOS Commercial |
$357.63
|
| Rate for Payer: HFN Commercial |
$373.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: Preferred Network Access Commercial |
$373.35
|
| Rate for Payer: Quartz Beloit One Network |
$172.92
|
| Rate for Payer: Quartz Commercial |
$224.01
|
| Rate for Payer: The Alliance Commercial |
$196.50
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
Ethosuximide Level
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 80339
|
| Hospital Charge Code |
977939
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$192.57 |
| Max. Negotiated Rate |
$361.56 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$337.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.29
|
| Rate for Payer: Cash Price |
$117.90
|
| Rate for Payer: Cigna Commercial |
$361.56
|
| Rate for Payer: Health EOS Commercial |
$349.77
|
| Rate for Payer: HFN Commercial |
$361.56
|
| Rate for Payer: Multiplan Commercial |
$314.40
|
| Rate for Payer: NAPHCARE Commercial |
$235.80
|
| Rate for Payer: Preferred Network Access Commercial |
$361.56
|
| Rate for Payer: Quartz Beloit One Network |
$192.57
|
| Rate for Payer: Quartz Commercial |
$235.80
|
| Rate for Payer: WEA Trust Commercial |
$216.15
|
| Rate for Payer: WPS Commercial |
$291.10
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Professional
|
Both
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.60 |
| Max. Negotiated Rate |
$533.90 |
| Rate for Payer: Aetna Commercial |
$533.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$483.32
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$533.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$281.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$337.20
|
| Rate for Payer: Health EOS Commercial |
$511.42
|
| Rate for Payer: HFN Commercial |
$533.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.60
|
| Rate for Payer: Multiplan Commercial |
$449.60
|
| Rate for Payer: Preferred Network Access Commercial |
$533.90
|
| Rate for Payer: Quartz Beloit One Network |
$247.28
|
| Rate for Payer: Quartz Commercial |
$320.34
|
| Rate for Payer: The Alliance Commercial |
$281.00
|
| Rate for Payer: WEA Trust Commercial |
$309.10
|
| Rate for Payer: WPS Commercial |
$416.27
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Facility
|
IP
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$275.38 |
| Max. Negotiated Rate |
$517.04 |
| Rate for Payer: Aetna Commercial |
$505.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$483.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.86
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$517.04
|
| Rate for Payer: Health EOS Commercial |
$500.18
|
| Rate for Payer: HFN Commercial |
$517.04
|
| Rate for Payer: Multiplan Commercial |
$449.60
|
| Rate for Payer: NAPHCARE Commercial |
$337.20
|
| Rate for Payer: Preferred Network Access Commercial |
$517.04
|
| Rate for Payer: Quartz Beloit One Network |
$275.38
|
| Rate for Payer: Quartz Commercial |
$337.20
|
| Rate for Payer: WEA Trust Commercial |
$309.10
|
| Rate for Payer: WPS Commercial |
$416.27
|
|
|
Ethylene Glycol/ UW Madison Adult
|
Facility
|
OP
|
$562.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552608
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.95 |
| Max. Negotiated Rate |
$517.04 |
| Rate for Payer: Aetna Commercial |
$505.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$483.32
|
| Rate for Payer: Aetna Managed Medicare |
$14.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.73
|
| Rate for Payer: Anthem Medicaid |
$7.95
|
| Rate for Payer: Anthem Medicare Advantage |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$297.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.90
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cash Price |
$168.60
|
| Rate for Payer: Cigna Commercial |
$517.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$314.50
|
| Rate for Payer: Dean Health Medicaid |
$7.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.90
|
| Rate for Payer: Health EOS Commercial |
$500.18
|
| Rate for Payer: HFN Commercial |
$517.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.90
|
| Rate for Payer: Managed Health Services Medicaid |
$8.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.90
|
| Rate for Payer: Multiplan Commercial |
$449.60
|
| Rate for Payer: NAPHCARE Commercial |
$22.35
|
| Rate for Payer: Preferred Network Access Commercial |
$517.04
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.95
|
| Rate for Payer: Quartz Beloit One Network |
$275.38
|
| Rate for Payer: Quartz Commercial |
$365.30
|
| Rate for Payer: Quartz Medicare Advantage |
$14.90
|
| Rate for Payer: The Alliance Commercial |
$59.60
|
| Rate for Payer: United Healthcare Medicaid |
$7.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.90
|
| Rate for Payer: United Healthcare PPO |
$421.50
|
| Rate for Payer: WEA Trust Commercial |
$309.10
|
| Rate for Payer: Wellcare Medicare |
$14.90
|
| Rate for Payer: WMAP Medicaid |
$7.95
|
| Rate for Payer: WPS Commercial |
$416.27
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.95 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna Commercial |
$486.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$464.40
|
| Rate for Payer: Aetna Managed Medicare |
$14.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.73
|
| Rate for Payer: Anthem Medicaid |
$7.95
|
| Rate for Payer: Anthem Medicare Advantage |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$286.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.90
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$302.18
|
| Rate for Payer: Dean Health Medicaid |
$7.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.90
|
| Rate for Payer: Health EOS Commercial |
$480.60
|
| Rate for Payer: HFN Commercial |
$496.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.90
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.90
|
| Rate for Payer: Managed Health Services Medicaid |
$8.27
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.90
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: NAPHCARE Commercial |
$22.35
|
| Rate for Payer: Preferred Network Access Commercial |
$496.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7.95
|
| Rate for Payer: Quartz Beloit One Network |
$264.60
|
| Rate for Payer: Quartz Commercial |
$351.00
|
| Rate for Payer: Quartz Medicare Advantage |
$14.90
|
| Rate for Payer: The Alliance Commercial |
$59.60
|
| Rate for Payer: United Healthcare Medicaid |
$7.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.90
|
| Rate for Payer: United Healthcare PPO |
$405.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: Wellcare Medicare |
$14.90
|
| Rate for Payer: WMAP Medicaid |
$7.95
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$264.60 |
| Max. Negotiated Rate |
$496.80 |
| Rate for Payer: Aetna Commercial |
$486.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$464.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$286.20
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$496.80
|
| Rate for Payer: Health EOS Commercial |
$480.60
|
| Rate for Payer: HFN Commercial |
$496.80
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: NAPHCARE Commercial |
$324.00
|
| Rate for Payer: Preferred Network Access Commercial |
$496.80
|
| Rate for Payer: Quartz Beloit One Network |
$264.60
|
| Rate for Payer: Quartz Commercial |
$324.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
|
Ethylene Glycol/ UW Madison Pediatric
|
Professional
|
Both
|
$540.00
|
|
|
Service Code
|
CPT 82693
|
| Hospital Charge Code |
4552609
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.60 |
| Max. Negotiated Rate |
$513.00 |
| Rate for Payer: Aetna Commercial |
$513.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$464.40
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cash Price |
$162.00
|
| Rate for Payer: Cigna Commercial |
$513.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$270.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.00
|
| Rate for Payer: Health EOS Commercial |
$491.40
|
| Rate for Payer: HFN Commercial |
$513.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.60
|
| Rate for Payer: Multiplan Commercial |
$432.00
|
| Rate for Payer: Preferred Network Access Commercial |
$513.00
|
| Rate for Payer: Quartz Beloit One Network |
$237.60
|
| Rate for Payer: Quartz Commercial |
$307.80
|
| Rate for Payer: The Alliance Commercial |
$270.00
|
| Rate for Payer: WEA Trust Commercial |
$297.00
|
| Rate for Payer: WPS Commercial |
$399.98
|
|
|
ET intubation - Resuscitation at Birth:
|
Facility
|
OP
|
$344.00
|
|
| Hospital Charge Code |
3000343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$96.32 |
| Max. Negotiated Rate |
$1,376.00 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Aetna Managed Medicare |
$96.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$223.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$172.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$165.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.50
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$258.00
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$223.60
|
| Rate for Payer: Quartz Medicare Advantage |
$206.40
|
| Rate for Payer: The Alliance Commercial |
$1,376.00
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
ET intubation - Resuscitation at Birth:
|
Facility
|
IP
|
$344.00
|
|
| Hospital Charge Code |
3000343
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.56 |
| Max. Negotiated Rate |
$316.48 |
| Rate for Payer: Aetna Commercial |
$309.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$295.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$182.32
|
| Rate for Payer: Cash Price |
$103.20
|
| Rate for Payer: Cigna Commercial |
$316.48
|
| Rate for Payer: Health EOS Commercial |
$306.16
|
| Rate for Payer: HFN Commercial |
$316.48
|
| Rate for Payer: Multiplan Commercial |
$275.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$316.48
|
| Rate for Payer: Quartz Beloit One Network |
$168.56
|
| Rate for Payer: Quartz Commercial |
$206.40
|
| Rate for Payer: WEA Trust Commercial |
$189.20
|
| Rate for Payer: WPS Commercial |
$254.80
|
|
|
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 |
$848.76 |
| Max. Negotiated Rate |
$1,832.55 |
| Rate for Payer: Aetna Commercial |
$1,832.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,658.94
|
| Rate for Payer: Anthem Commercial |
$981.56
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,832.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,156.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,157.40
|
| Rate for Payer: Health EOS Commercial |
$1,755.39
|
| Rate for Payer: HFN Commercial |
$1,832.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,468.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,468.91
|
| Rate for Payer: Multiplan Commercial |
$1,543.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,832.55
|
| Rate for Payer: Quartz Beloit One Network |
$848.76
|
| Rate for Payer: Quartz Commercial |
$1,099.53
|
| Rate for Payer: The Alliance Commercial |
$964.50
|
| Rate for Payer: United Healthcare Medicaid |
$1,156.28
|
| Rate for Payer: WEA Trust Commercial |
$1,060.95
|
| Rate for Payer: WPS Commercial |
$1,428.81
|
|
|
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 |
$945.21 |
| Max. Negotiated Rate |
$1,774.68 |
| Rate for Payer: Aetna Commercial |
$1,736.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,658.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,022.37
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,774.68
|
| Rate for Payer: Health EOS Commercial |
$1,716.81
|
| Rate for Payer: HFN Commercial |
$1,774.68
|
| Rate for Payer: Multiplan Commercial |
$1,543.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,157.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,774.68
|
| Rate for Payer: Quartz Beloit One Network |
$945.21
|
| Rate for Payer: Quartz Commercial |
$1,157.40
|
| Rate for Payer: WEA Trust Commercial |
$1,060.95
|
| Rate for Payer: WPS Commercial |
$1,428.81
|
|
|
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 |
$540.12 |
| Max. Negotiated Rate |
$7,716.00 |
| Rate for Payer: Aetna Commercial |
$1,736.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,658.94
|
| Rate for Payer: Aetna Managed Medicare |
$540.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,253.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$964.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$925.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,022.37
|
| Rate for Payer: Cash Price |
$578.70
|
| Rate for Payer: Cigna Commercial |
$1,774.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,079.47
|
| Rate for Payer: Health EOS Commercial |
$1,716.81
|
| Rate for Payer: HFN Commercial |
$1,774.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,446.75
|
| Rate for Payer: Multiplan Commercial |
$1,543.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,157.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,774.68
|
| Rate for Payer: Quartz Beloit One Network |
$945.21
|
| Rate for Payer: Quartz Commercial |
$1,253.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,157.40
|
| Rate for Payer: The Alliance Commercial |
$7,716.00
|
| Rate for Payer: WEA Trust Commercial |
$1,060.95
|
| Rate for Payer: WPS Commercial |
$1,428.81
|
|
|
E.T. Tube 2.0 - 8.0
|
Facility
|
IP
|
$3.00
|
|
| Hospital Charge Code |
3149564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
E.T. Tube 2.0 - 8.0
|
Facility
|
OP
|
$3.00
|
|
| Hospital Charge Code |
3149564
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.68
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Euflexxa 1 Unit = 1 Unit Charge
|
Facility
|
OP
|
$2,615.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
5386676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$2,405.80 |
| Rate for Payer: Aetna Commercial |
$2,353.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,248.90
|
| Rate for Payer: Aetna Managed Medicare |
$127.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,699.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,307.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,255.20
|
| Rate for Payer: Anthem Medicare Advantage |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,385.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.30
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,405.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$127.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$127.30
|
| Rate for Payer: Health EOS Commercial |
$2,327.35
|
| Rate for Payer: HFN Commercial |
$2,405.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$473.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$127.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$127.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$127.30
|
| Rate for Payer: Multiplan Commercial |
$2,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$190.95
|
| Rate for Payer: Preferred Network Access Commercial |
$2,405.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,281.35
|
| Rate for Payer: Quartz Commercial |
$1,699.75
|
| Rate for Payer: Quartz Medicare Advantage |
$127.30
|
| Rate for Payer: The Alliance Commercial |
$509.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.30
|
| Rate for Payer: WEA Trust Commercial |
$1,438.25
|
| Rate for Payer: Wellcare Medicare |
$127.30
|
| Rate for Payer: WPS Commercial |
$288.93
|
|
|
Euflexxa 1 Unit = 1 Unit Charge
|
Facility
|
IP
|
$2,615.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
5386676
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,281.35 |
| Max. Negotiated Rate |
$2,405.80 |
| Rate for Payer: Aetna Commercial |
$2,353.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,248.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,385.95
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,405.80
|
| Rate for Payer: Health EOS Commercial |
$2,327.35
|
| Rate for Payer: HFN Commercial |
$2,405.80
|
| Rate for Payer: Multiplan Commercial |
$2,092.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,569.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,405.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,281.35
|
| Rate for Payer: Quartz Commercial |
$1,569.00
|
| Rate for Payer: WEA Trust Commercial |
$1,438.25
|
| Rate for Payer: WPS Commercial |
$1,936.93
|
|
|
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 |
$115.57 |
| Max. Negotiated Rate |
$2,484.25 |
| Rate for Payer: Aetna Commercial |
$2,484.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,248.90
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cash Price |
$784.50
|
| Rate for Payer: Cigna Commercial |
$2,484.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$115.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.57
|
| Rate for Payer: Health EOS Commercial |
$2,379.65
|
| Rate for Payer: HFN Commercial |
$2,484.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.25
|
| Rate for Payer: Multiplan Commercial |
$2,092.00
|
| Rate for Payer: Preferred Network Access Commercial |
$2,484.25
|
| Rate for Payer: Quartz Beloit One Network |
$1,150.60
|
| Rate for Payer: Quartz Commercial |
$1,490.55
|
| Rate for Payer: The Alliance Commercial |
$1,307.50
|
| Rate for Payer: United Healthcare Medicaid |
$115.57
|
| Rate for Payer: WEA Trust Commercial |
$1,438.25
|
| Rate for Payer: WPS Commercial |
$288.93
|
|
|
Euflexxa inj per dose J7323
|
Professional
|
Both
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$115.57 |
| Max. Negotiated Rate |
$2,532.70 |
| Rate for Payer: Aetna Commercial |
$2,532.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,292.76
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,532.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$115.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.57
|
| Rate for Payer: Health EOS Commercial |
$2,426.06
|
| Rate for Payer: HFN Commercial |
$2,532.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$202.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$202.25
|
| Rate for Payer: Multiplan Commercial |
$2,132.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,532.70
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.04
|
| Rate for Payer: Quartz Commercial |
$1,519.62
|
| Rate for Payer: The Alliance Commercial |
$1,333.00
|
| Rate for Payer: United Healthcare Medicaid |
$115.57
|
| Rate for Payer: WEA Trust Commercial |
$1,466.30
|
| Rate for Payer: WPS Commercial |
$288.93
|
|
|
Euflexxa inj per dose J7323
|
Facility
|
IP
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,306.34 |
| Max. Negotiated Rate |
$2,452.72 |
| Rate for Payer: Aetna Commercial |
$2,399.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,292.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,412.98
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,452.72
|
| Rate for Payer: Health EOS Commercial |
$2,372.74
|
| Rate for Payer: HFN Commercial |
$2,452.72
|
| Rate for Payer: Multiplan Commercial |
$2,132.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,599.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,452.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.34
|
| Rate for Payer: Quartz Commercial |
$1,599.60
|
| Rate for Payer: WEA Trust Commercial |
$1,466.30
|
| Rate for Payer: WPS Commercial |
$1,974.71
|
|
|
Euflexxa inj per dose J7323
|
Facility
|
OP
|
$2,666.00
|
|
|
Service Code
|
HCPCS J7323
|
| Hospital Charge Code |
4422622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$127.30 |
| Max. Negotiated Rate |
$2,452.72 |
| Rate for Payer: Aetna Commercial |
$2,399.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,292.76
|
| Rate for Payer: Aetna Managed Medicare |
$127.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,732.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,333.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,279.68
|
| Rate for Payer: Anthem Medicare Advantage |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,412.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$127.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$127.30
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cash Price |
$799.80
|
| Rate for Payer: Cigna Commercial |
$2,452.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$127.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$152.90
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$127.30
|
| Rate for Payer: Health EOS Commercial |
$2,372.74
|
| Rate for Payer: HFN Commercial |
$2,452.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$473.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$127.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$127.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$127.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$127.30
|
| Rate for Payer: Multiplan Commercial |
$2,132.80
|
| Rate for Payer: NAPHCARE Commercial |
$190.95
|
| Rate for Payer: Preferred Network Access Commercial |
$2,452.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,306.34
|
| Rate for Payer: Quartz Commercial |
$1,732.90
|
| Rate for Payer: Quartz Medicare Advantage |
$127.30
|
| Rate for Payer: The Alliance Commercial |
$509.20
|
| Rate for Payer: United Healthcare Medicare Advantage |
$127.30
|
| Rate for Payer: WEA Trust Commercial |
$1,466.30
|
| Rate for Payer: Wellcare Medicare |
$127.30
|
| Rate for Payer: WPS Commercial |
$288.93
|
|
|
EUSTACHIAN TUBE BALLOON SYSTEM ACCLARENT AERA EU061655
|
Facility
|
IP
|
$11,334.00
|
|
|
Service Code
|
HCPCS C9745
|
| Hospital Charge Code |
5306666
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,553.66 |
| Max. Negotiated Rate |
$10,427.28 |
| Rate for Payer: Aetna Commercial |
$10,200.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,747.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,007.02
|
| Rate for Payer: Cash Price |
$3,400.20
|
| Rate for Payer: Cigna Commercial |
$10,427.28
|
| Rate for Payer: Health EOS Commercial |
$10,087.26
|
| Rate for Payer: HFN Commercial |
$10,427.28
|
| Rate for Payer: Multiplan Commercial |
$9,067.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,800.40
|
| Rate for Payer: Preferred Network Access Commercial |
$10,427.28
|
| Rate for Payer: Quartz Beloit One Network |
$5,553.66
|
| Rate for Payer: Quartz Commercial |
$6,800.40
|
| Rate for Payer: WEA Trust Commercial |
$6,233.70
|
| Rate for Payer: WPS Commercial |
$8,395.09
|
|
