|
flumazenil 0.1 mg/mL IV Sol [Med]
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2983101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$36.80 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
flumazenil 0.1 mg/mL IV Sol [Med]
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
2983101
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: Aetna Commercial |
$36.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$34.40
|
| Rate for Payer: Aetna Managed Medicare |
$11.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$21.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna Commercial |
$36.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Health EOS Commercial |
$35.60
|
| Rate for Payer: HFN Commercial |
$36.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$32.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.00
|
| Rate for Payer: Preferred Network Access Commercial |
$36.80
|
| Rate for Payer: Quartz Beloit One Network |
$19.60
|
| Rate for Payer: Quartz Commercial |
$26.00
|
| Rate for Payer: Quartz Medicare Advantage |
$24.00
|
| Rate for Payer: The Alliance Commercial |
$160.00
|
| Rate for Payer: WEA Trust Commercial |
$22.00
|
| Rate for Payer: WPS Commercial |
$29.63
|
|
|
Flunitrazepam & Metabolites, Quant
|
Professional
|
Both
|
$191.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$181.45 |
| Rate for Payer: Aetna Commercial |
$181.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$181.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$95.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$114.60
|
| Rate for Payer: Health EOS Commercial |
$173.81
|
| Rate for Payer: HFN Commercial |
$181.45
|
| 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 |
$152.80
|
| Rate for Payer: Preferred Network Access Commercial |
$181.45
|
| Rate for Payer: Quartz Beloit One Network |
$84.04
|
| Rate for Payer: Quartz Commercial |
$108.87
|
| Rate for Payer: The Alliance Commercial |
$95.50
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Flunitrazepam & Metabolites, Quant
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$53.48 |
| Max. Negotiated Rate |
$764.00 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Aetna Managed Medicare |
$53.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$124.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$95.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$91.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$106.88
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.25
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$124.15
|
| Rate for Payer: Quartz Medicare Advantage |
$114.60
|
| Rate for Payer: The Alliance Commercial |
$764.00
|
| Rate for Payer: United Healthcare PPO |
$143.25
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Flunitrazepam & Metabolites, Quant
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$93.59 |
| Max. Negotiated Rate |
$175.72 |
| Rate for Payer: Aetna Commercial |
$171.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$164.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$101.23
|
| Rate for Payer: Cash Price |
$57.30
|
| Rate for Payer: Cigna Commercial |
$175.72
|
| Rate for Payer: Health EOS Commercial |
$169.99
|
| Rate for Payer: HFN Commercial |
$175.72
|
| Rate for Payer: Multiplan Commercial |
$152.80
|
| Rate for Payer: NAPHCARE Commercial |
$114.60
|
| Rate for Payer: Preferred Network Access Commercial |
$175.72
|
| Rate for Payer: Quartz Beloit One Network |
$93.59
|
| Rate for Payer: Quartz Commercial |
$114.60
|
| Rate for Payer: WEA Trust Commercial |
$105.05
|
| Rate for Payer: WPS Commercial |
$141.47
|
|
|
Flunitrazepam & Metabolites, Quant, Urine
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$89.60 |
| Max. Negotiated Rate |
$1,280.00 |
| Rate for Payer: Aetna Commercial |
$288.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$275.20
|
| Rate for Payer: Aetna Managed Medicare |
$89.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$153.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$294.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$179.07
|
| Rate for Payer: Health EOS Commercial |
$284.80
|
| Rate for Payer: HFN Commercial |
$294.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$240.00
|
| Rate for Payer: Multiplan Commercial |
$256.00
|
| Rate for Payer: NAPHCARE Commercial |
$192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$294.40
|
| Rate for Payer: Quartz Beloit One Network |
$156.80
|
| Rate for Payer: Quartz Commercial |
$208.00
|
| Rate for Payer: Quartz Medicare Advantage |
$192.00
|
| Rate for Payer: The Alliance Commercial |
$1,280.00
|
| Rate for Payer: United Healthcare PPO |
$240.00
|
| Rate for Payer: WEA Trust Commercial |
$176.00
|
| Rate for Payer: WPS Commercial |
$237.02
|
|
|
Flunitrazepam & Metabolites, Quant, Urine
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$304.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$275.20
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$304.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$160.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$192.00
|
| Rate for Payer: Health EOS Commercial |
$291.20
|
| Rate for Payer: HFN Commercial |
$304.00
|
| 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 |
$256.00
|
| Rate for Payer: Preferred Network Access Commercial |
$304.00
|
| Rate for Payer: Quartz Beloit One Network |
$140.80
|
| Rate for Payer: Quartz Commercial |
$182.40
|
| Rate for Payer: The Alliance Commercial |
$160.00
|
| Rate for Payer: WEA Trust Commercial |
$176.00
|
| Rate for Payer: WPS Commercial |
$237.02
|
|
|
Flunitrazepam & Metabolites, Quant, Urine
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
3907355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.80 |
| Max. Negotiated Rate |
$294.40 |
| Rate for Payer: Aetna Commercial |
$288.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$275.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$169.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna Commercial |
$294.40
|
| Rate for Payer: Health EOS Commercial |
$284.80
|
| Rate for Payer: HFN Commercial |
$294.40
|
| Rate for Payer: Multiplan Commercial |
$256.00
|
| Rate for Payer: NAPHCARE Commercial |
$192.00
|
| Rate for Payer: Preferred Network Access Commercial |
$294.40
|
| Rate for Payer: Quartz Beloit One Network |
$156.80
|
| Rate for Payer: Quartz Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$176.00
|
| Rate for Payer: WPS Commercial |
$237.02
|
|
|
Fluorescent Treponemal Antibody-Absorption
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
977953
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.13 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$13.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.17
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.98
|
| Rate for Payer: Anthem Medicaid |
$11.13
|
| Rate for Payer: Anthem Medicare Advantage |
$13.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.24
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Dean Health Medicaid |
$11.13
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.24
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.24
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$11.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.24
|
| Rate for Payer: Managed Health Services Medicaid |
$11.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.24
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.24
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$19.86
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11.13
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$13.24
|
| Rate for Payer: The Alliance Commercial |
$52.96
|
| Rate for Payer: United Healthcare Medicaid |
$11.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.24
|
| Rate for Payer: United Healthcare PPO |
$113.25
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: Wellcare Medicare |
$13.24
|
| Rate for Payer: WMAP Medicaid |
$11.13
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Fluorescent Treponemal Antibody-Absorption
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
977953
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Fluorescent Treponemal Antibody-Absorption
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 86780
|
| Hospital Charge Code |
977953
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.74 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: HFN Commercial |
$143.45
|
| Rate for Payer: Health EOS Commercial |
$137.41
|
| Rate for Payer: Aetna Commercial |
$143.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$143.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.74
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.45
|
| Rate for Payer: Quartz Beloit One Network |
$66.44
|
| Rate for Payer: Quartz Commercial |
$86.07
|
| Rate for Payer: The Alliance Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Fluorine-18 FDG
|
Facility
|
IP
|
$2,427.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
1486820
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,189.23 |
| Max. Negotiated Rate |
$2,232.84 |
| Rate for Payer: Aetna Commercial |
$2,184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,087.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,286.31
|
| Rate for Payer: Cash Price |
$728.10
|
| Rate for Payer: Cigna Commercial |
$2,232.84
|
| Rate for Payer: Health EOS Commercial |
$2,160.03
|
| Rate for Payer: HFN Commercial |
$2,232.84
|
| Rate for Payer: Multiplan Commercial |
$1,941.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,456.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,232.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,189.23
|
| Rate for Payer: Quartz Commercial |
$1,456.20
|
| Rate for Payer: WEA Trust Commercial |
$1,334.85
|
| Rate for Payer: WPS Commercial |
$1,797.68
|
|
|
Fluorine-18 FDG
|
Professional
|
Both
|
$2,427.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
1486820
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$467.49 |
| Max. Negotiated Rate |
$2,305.65 |
| Rate for Payer: Aetna Commercial |
$2,305.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,087.22
|
| Rate for Payer: Cash Price |
$728.10
|
| Rate for Payer: Cash Price |
$728.10
|
| Rate for Payer: Cigna Commercial |
$2,305.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,213.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,456.20
|
| Rate for Payer: Health EOS Commercial |
$2,208.57
|
| Rate for Payer: HFN Commercial |
$2,305.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$467.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$467.49
|
| Rate for Payer: Multiplan Commercial |
$1,941.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,305.65
|
| Rate for Payer: Quartz Beloit One Network |
$1,067.88
|
| Rate for Payer: Quartz Commercial |
$1,383.39
|
| Rate for Payer: The Alliance Commercial |
$1,213.50
|
| Rate for Payer: WEA Trust Commercial |
$1,334.85
|
| Rate for Payer: WPS Commercial |
$1,797.68
|
|
|
Fluorine-18 FDG
|
Facility
|
OP
|
$2,427.00
|
|
|
Service Code
|
HCPCS A9552
|
| Hospital Charge Code |
1486820
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$679.56 |
| Max. Negotiated Rate |
$9,708.00 |
| Rate for Payer: Aetna Commercial |
$2,184.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,087.22
|
| Rate for Payer: Aetna Managed Medicare |
$679.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,577.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,213.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,164.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,286.31
|
| Rate for Payer: Cash Price |
$728.10
|
| Rate for Payer: Cigna Commercial |
$2,232.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,358.15
|
| Rate for Payer: Health EOS Commercial |
$2,160.03
|
| Rate for Payer: HFN Commercial |
$2,232.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,820.25
|
| Rate for Payer: Multiplan Commercial |
$1,941.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,456.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,232.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,189.23
|
| Rate for Payer: Quartz Commercial |
$1,577.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,456.20
|
| Rate for Payer: The Alliance Commercial |
$9,708.00
|
| Rate for Payer: WEA Trust Commercial |
$1,334.85
|
| Rate for Payer: WPS Commercial |
$1,797.68
|
|
|
Fluoro Guidance Needle Loc Spine 77003
|
Professional
|
Both
|
$527.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
6180118
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$231.88 |
| Max. Negotiated Rate |
$500.65 |
| Rate for Payer: Aetna Commercial |
$500.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$453.22
|
| Rate for Payer: Cash Price |
$158.10
|
| Rate for Payer: Cash Price |
$158.10
|
| Rate for Payer: Cash Price |
$158.10
|
| Rate for Payer: Cigna Commercial |
$500.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$316.20
|
| Rate for Payer: Health EOS Commercial |
$479.57
|
| Rate for Payer: HFN Commercial |
$500.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$356.53
|
| Rate for Payer: Multiplan Commercial |
$421.60
|
| Rate for Payer: Preferred Network Access Commercial |
$500.65
|
| Rate for Payer: Quartz Beloit One Network |
$231.88
|
| Rate for Payer: Quartz Commercial |
$300.39
|
| Rate for Payer: The Alliance Commercial |
$263.50
|
| Rate for Payer: WEA Trust Commercial |
$289.85
|
| Rate for Payer: WPS Commercial |
$390.35
|
|
|
Fluoro Guidance Needle Loc Spine 7700326
|
Professional
|
Both
|
$526.00
|
|
|
Service Code
|
CPT 77003 26
|
| Hospital Charge Code |
5313664
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$99.72 |
| Max. Negotiated Rate |
$499.70 |
| Rate for Payer: Aetna Commercial |
$499.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.36
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$499.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$263.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$315.60
|
| Rate for Payer: Health EOS Commercial |
$478.66
|
| Rate for Payer: HFN Commercial |
$499.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$99.72
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: Preferred Network Access Commercial |
$499.70
|
| Rate for Payer: Quartz Beloit One Network |
$231.44
|
| Rate for Payer: Quartz Commercial |
$299.82
|
| Rate for Payer: The Alliance Commercial |
$263.00
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
Fluoro Guidance Spine Inj
|
Professional
|
Both
|
$846.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
3072751
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$356.53 |
| Max. Negotiated Rate |
$803.70 |
| Rate for Payer: Aetna Commercial |
$803.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.56
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$803.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$423.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$507.60
|
| Rate for Payer: Health EOS Commercial |
$769.86
|
| Rate for Payer: HFN Commercial |
$803.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$356.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$356.53
|
| Rate for Payer: Multiplan Commercial |
$676.80
|
| Rate for Payer: Preferred Network Access Commercial |
$803.70
|
| Rate for Payer: Quartz Beloit One Network |
$372.24
|
| Rate for Payer: Quartz Commercial |
$482.22
|
| Rate for Payer: The Alliance Commercial |
$423.00
|
| Rate for Payer: WEA Trust Commercial |
$465.30
|
| Rate for Payer: WPS Commercial |
$626.63
|
|
|
Fluoro Guidance Spine Inj
|
Facility
|
OP
|
$846.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
3072751
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$236.88 |
| Max. Negotiated Rate |
$3,384.00 |
| Rate for Payer: Aetna Commercial |
$761.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.56
|
| Rate for Payer: Aetna Managed Medicare |
$236.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$549.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$423.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$406.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.38
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$778.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$473.42
|
| Rate for Payer: Health EOS Commercial |
$752.94
|
| Rate for Payer: HFN Commercial |
$778.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$634.50
|
| Rate for Payer: Multiplan Commercial |
$676.80
|
| Rate for Payer: NAPHCARE Commercial |
$507.60
|
| Rate for Payer: Preferred Network Access Commercial |
$778.32
|
| Rate for Payer: Quartz Beloit One Network |
$414.54
|
| Rate for Payer: Quartz Commercial |
$549.90
|
| Rate for Payer: Quartz Medicare Advantage |
$507.60
|
| Rate for Payer: The Alliance Commercial |
$3,384.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$465.30
|
| Rate for Payer: WPS Commercial |
$626.63
|
|
|
Fluoro Guidance Spine Inj
|
Facility
|
IP
|
$846.00
|
|
|
Service Code
|
CPT 77003
|
| Hospital Charge Code |
3072751
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$414.54 |
| Max. Negotiated Rate |
$778.32 |
| Rate for Payer: Aetna Commercial |
$761.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$727.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$448.38
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cigna Commercial |
$778.32
|
| Rate for Payer: Health EOS Commercial |
$752.94
|
| Rate for Payer: HFN Commercial |
$778.32
|
| Rate for Payer: Multiplan Commercial |
$676.80
|
| Rate for Payer: NAPHCARE Commercial |
$507.60
|
| Rate for Payer: Preferred Network Access Commercial |
$778.32
|
| Rate for Payer: Quartz Beloit One Network |
$414.54
|
| Rate for Payer: Quartz Commercial |
$507.60
|
| Rate for Payer: WEA Trust Commercial |
$465.30
|
| Rate for Payer: WPS Commercial |
$626.63
|
|
|
FLUOROGUIDE FOR VEIN DEVICE 7700126
|
Professional
|
Both
|
$242.00
|
|
|
Service Code
|
CPT 77001 26
|
| Hospital Charge Code |
3015313
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$62.20 |
| Max. Negotiated Rate |
$229.90 |
| Rate for Payer: Aetna Commercial |
$229.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.12
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cash Price |
$72.60
|
| Rate for Payer: Cigna Commercial |
$229.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.20
|
| Rate for Payer: Health EOS Commercial |
$220.22
|
| Rate for Payer: HFN Commercial |
$229.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.20
|
| Rate for Payer: Multiplan Commercial |
$193.60
|
| Rate for Payer: Preferred Network Access Commercial |
$229.90
|
| Rate for Payer: Quartz Beloit One Network |
$106.48
|
| Rate for Payer: Quartz Commercial |
$137.94
|
| Rate for Payer: The Alliance Commercial |
$121.00
|
| Rate for Payer: WEA Trust Commercial |
$133.10
|
| Rate for Payer: WPS Commercial |
$179.25
|
|
|
Fluoroscope Exam 76000
|
Professional
|
Both
|
$28.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
3303478
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$12.32 |
| Max. Negotiated Rate |
$143.21 |
| Rate for Payer: Aetna Commercial |
$26.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$24.08
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cash Price |
$8.40
|
| Rate for Payer: Cigna Commercial |
$26.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.80
|
| Rate for Payer: Health EOS Commercial |
$25.48
|
| Rate for Payer: HFN Commercial |
$26.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.21
|
| Rate for Payer: Multiplan Commercial |
$22.40
|
| Rate for Payer: Preferred Network Access Commercial |
$26.60
|
| Rate for Payer: Quartz Beloit One Network |
$12.32
|
| Rate for Payer: Quartz Commercial |
$15.96
|
| Rate for Payer: The Alliance Commercial |
$14.00
|
| Rate for Payer: WEA Trust Commercial |
$15.40
|
| Rate for Payer: WPS Commercial |
$20.74
|
|
|
Fluoroscope Exam 7600026
|
Professional
|
Both
|
$136.00
|
|
|
Service Code
|
CPT 76000 26
|
| Hospital Charge Code |
3137543
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.19 |
| Max. Negotiated Rate |
$129.20 |
| Rate for Payer: Aetna Commercial |
$129.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$116.96
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$68.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.60
|
| Rate for Payer: Health EOS Commercial |
$123.76
|
| Rate for Payer: HFN Commercial |
$129.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.19
|
| Rate for Payer: Multiplan Commercial |
$108.80
|
| Rate for Payer: Preferred Network Access Commercial |
$129.20
|
| Rate for Payer: Quartz Beloit One Network |
$59.84
|
| Rate for Payer: Quartz Commercial |
$77.52
|
| Rate for Payer: The Alliance Commercial |
$68.00
|
| Rate for Payer: WEA Trust Commercial |
$74.80
|
| Rate for Payer: WPS Commercial |
$100.74
|
|
|
FLUORO W/JOINT INJECTION ONLY
|
Facility
|
IP
|
$1,485.00
|
|
| Hospital Charge Code |
5294612
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$727.65 |
| Max. Negotiated Rate |
$1,366.20 |
| Rate for Payer: Aetna Commercial |
$1,336.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,277.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.05
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cigna Commercial |
$1,366.20
|
| Rate for Payer: Health EOS Commercial |
$1,321.65
|
| Rate for Payer: HFN Commercial |
$1,366.20
|
| Rate for Payer: Multiplan Commercial |
$1,188.00
|
| Rate for Payer: NAPHCARE Commercial |
$891.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,366.20
|
| Rate for Payer: Quartz Beloit One Network |
$727.65
|
| Rate for Payer: Quartz Commercial |
$891.00
|
| Rate for Payer: WEA Trust Commercial |
$816.75
|
| Rate for Payer: WPS Commercial |
$1,099.94
|
|
|
FLUORO W/JOINT INJECTION ONLY
|
Facility
|
OP
|
$1,485.00
|
|
| Hospital Charge Code |
5294612
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$415.80 |
| Max. Negotiated Rate |
$5,940.00 |
| Rate for Payer: Aetna Commercial |
$1,336.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,277.10
|
| Rate for Payer: Aetna Managed Medicare |
$415.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$965.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$742.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$712.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$787.05
|
| Rate for Payer: Cash Price |
$445.50
|
| Rate for Payer: Cigna Commercial |
$1,366.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$831.01
|
| Rate for Payer: Health EOS Commercial |
$1,321.65
|
| Rate for Payer: HFN Commercial |
$1,366.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,113.75
|
| Rate for Payer: Multiplan Commercial |
$1,188.00
|
| Rate for Payer: NAPHCARE Commercial |
$891.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,366.20
|
| Rate for Payer: Quartz Beloit One Network |
$727.65
|
| Rate for Payer: Quartz Commercial |
$965.25
|
| Rate for Payer: Quartz Medicare Advantage |
$891.00
|
| Rate for Payer: The Alliance Commercial |
$5,940.00
|
| Rate for Payer: WEA Trust Commercial |
$816.75
|
| Rate for Payer: WPS Commercial |
$1,099.94
|
|
|
Fluoxetine Level
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
978117
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$80.06 |
| Max. Negotiated Rate |
$502.55 |
| Rate for Payer: Aetna Commercial |
$502.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$502.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$264.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$317.40
|
| Rate for Payer: Health EOS Commercial |
$481.39
|
| Rate for Payer: HFN Commercial |
$502.55
|
| 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 |
$423.20
|
| Rate for Payer: Preferred Network Access Commercial |
$502.55
|
| Rate for Payer: Quartz Beloit One Network |
$232.76
|
| Rate for Payer: Quartz Commercial |
$301.53
|
| Rate for Payer: The Alliance Commercial |
$264.50
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$391.83
|
|
