|
HIP STEM ACCOLADE SZ 4 6077-0535
|
Facility
|
OP
|
$7,599.00
|
|
| Hospital Charge Code |
3922761
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,212.83 |
| Max. Negotiated Rate |
$7,270.72 |
| Rate for Payer: Aetna Commercial |
$7,112.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,796.55
|
| Rate for Payer: Aetna Managed Medicare |
$2,212.83
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,136.92
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,951.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,793.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,188.57
|
| Rate for Payer: Cash Price |
$2,279.70
|
| Rate for Payer: Cigna Commercial |
$7,270.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,422.62
|
| Rate for Payer: Health EOS Commercial |
$7,033.63
|
| Rate for Payer: HFN Commercial |
$7,270.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,927.22
|
| Rate for Payer: Multiplan Commercial |
$6,322.37
|
| Rate for Payer: NAPHCARE Commercial |
$4,741.78
|
| Rate for Payer: Preferred Network Access Commercial |
$7,270.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,872.45
|
| Rate for Payer: Quartz Commercial |
$5,136.92
|
| Rate for Payer: Quartz Medicare Advantage |
$4,741.78
|
| Rate for Payer: The Alliance Commercial |
$3,951.48
|
| Rate for Payer: WEA Trust Commercial |
$4,346.63
|
| Rate for Payer: WPS Commercial |
$5,853.51
|
|
|
HIP STEM ACCOLADE SZ 5 6077-0537
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
3995313
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 5 6077-0537
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
3995313
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 6 6077-0637
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
4079275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 6 6077-0637
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4079275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 7 6077-0740
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
4518637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 7 6077-0740
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4518637
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 8 6077-0840
|
Facility
|
IP
|
$7,318.00
|
|
| Hospital Charge Code |
4518638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,729.25 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,566.43
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM ACCOLADE SZ 8 6077-0840
|
Facility
|
OP
|
$7,318.00
|
|
| Hospital Charge Code |
4518638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.00 |
| Max. Negotiated Rate |
$7,001.86 |
| Rate for Payer: Aetna Commercial |
$6,849.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,545.22
|
| Rate for Payer: Aetna Managed Medicare |
$2,131.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,946.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,805.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,653.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,033.68
|
| Rate for Payer: Cash Price |
$2,195.40
|
| Rate for Payer: Cigna Commercial |
$7,001.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,259.08
|
| Rate for Payer: Health EOS Commercial |
$6,773.54
|
| Rate for Payer: HFN Commercial |
$7,001.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,708.04
|
| Rate for Payer: Multiplan Commercial |
$6,088.58
|
| Rate for Payer: NAPHCARE Commercial |
$4,566.43
|
| Rate for Payer: Preferred Network Access Commercial |
$7,001.86
|
| Rate for Payer: Quartz Beloit One Network |
$3,729.25
|
| Rate for Payer: Quartz Commercial |
$4,946.97
|
| Rate for Payer: Quartz Medicare Advantage |
$4,566.43
|
| Rate for Payer: The Alliance Commercial |
$3,805.36
|
| Rate for Payer: WEA Trust Commercial |
$4,185.90
|
| Rate for Payer: WPS Commercial |
$5,637.06
|
|
|
HIP STEM SECUR-FIT SZ 7 6051-0730S
|
Facility
|
IP
|
$17,236.00
|
|
| Hospital Charge Code |
3072550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,783.47 |
| Max. Negotiated Rate |
$16,491.40 |
| Rate for Payer: Aetna Commercial |
$16,132.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,415.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,500.48
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$16,491.40
|
| Rate for Payer: Health EOS Commercial |
$15,953.64
|
| Rate for Payer: HFN Commercial |
$16,491.40
|
| Rate for Payer: Multiplan Commercial |
$14,340.35
|
| Rate for Payer: Preferred Network Access Commercial |
$16,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$8,783.47
|
| Rate for Payer: Quartz Commercial |
$10,755.26
|
| Rate for Payer: WEA Trust Commercial |
$9,858.99
|
| Rate for Payer: WPS Commercial |
$13,276.89
|
|
|
HIP STEM SECUR-FIT SZ 7 6051-0730S
|
Facility
|
OP
|
$17,236.00
|
|
| Hospital Charge Code |
3072550
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,019.12 |
| Max. Negotiated Rate |
$16,491.40 |
| Rate for Payer: Aetna Commercial |
$16,132.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,415.88
|
| Rate for Payer: Aetna Managed Medicare |
$5,019.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,651.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,962.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,604.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,500.48
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$16,491.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,031.35
|
| Rate for Payer: Health EOS Commercial |
$15,953.64
|
| Rate for Payer: HFN Commercial |
$16,491.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,444.08
|
| Rate for Payer: Multiplan Commercial |
$14,340.35
|
| Rate for Payer: NAPHCARE Commercial |
$10,755.26
|
| Rate for Payer: Preferred Network Access Commercial |
$16,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$8,783.47
|
| Rate for Payer: Quartz Commercial |
$11,651.54
|
| Rate for Payer: Quartz Medicare Advantage |
$10,755.26
|
| Rate for Payer: The Alliance Commercial |
$8,962.72
|
| Rate for Payer: WEA Trust Commercial |
$9,858.99
|
| Rate for Payer: WPS Commercial |
$13,276.89
|
|
|
HIP STEM SECUR-FIT SZ 8 6052-0830S
|
Facility
|
OP
|
$17,236.00
|
|
| Hospital Charge Code |
3072477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,019.12 |
| Max. Negotiated Rate |
$16,491.40 |
| Rate for Payer: Aetna Commercial |
$16,132.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,415.88
|
| Rate for Payer: Aetna Managed Medicare |
$5,019.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,651.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,962.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,604.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,500.48
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$16,491.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,031.35
|
| Rate for Payer: Health EOS Commercial |
$15,953.64
|
| Rate for Payer: HFN Commercial |
$16,491.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,444.08
|
| Rate for Payer: Multiplan Commercial |
$14,340.35
|
| Rate for Payer: NAPHCARE Commercial |
$10,755.26
|
| Rate for Payer: Preferred Network Access Commercial |
$16,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$8,783.47
|
| Rate for Payer: Quartz Commercial |
$11,651.54
|
| Rate for Payer: Quartz Medicare Advantage |
$10,755.26
|
| Rate for Payer: The Alliance Commercial |
$8,962.72
|
| Rate for Payer: WEA Trust Commercial |
$9,858.99
|
| Rate for Payer: WPS Commercial |
$13,276.89
|
|
|
HIP STEM SECUR-FIT SZ 8 6052-0830S
|
Facility
|
IP
|
$17,236.00
|
|
| Hospital Charge Code |
3072477
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,783.47 |
| Max. Negotiated Rate |
$16,491.40 |
| Rate for Payer: Aetna Commercial |
$16,132.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,415.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,500.48
|
| Rate for Payer: Cash Price |
$5,170.80
|
| Rate for Payer: Cigna Commercial |
$16,491.40
|
| Rate for Payer: Health EOS Commercial |
$15,953.64
|
| Rate for Payer: HFN Commercial |
$16,491.40
|
| Rate for Payer: Multiplan Commercial |
$14,340.35
|
| Rate for Payer: Preferred Network Access Commercial |
$16,491.40
|
| Rate for Payer: Quartz Beloit One Network |
$8,783.47
|
| Rate for Payer: Quartz Commercial |
$10,755.26
|
| Rate for Payer: WEA Trust Commercial |
$9,858.99
|
| Rate for Payer: WPS Commercial |
$13,276.89
|
|
|
Histamine
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$443.61 |
| Rate for Payer: Aetna Commercial |
$443.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Aetna Managed Medicare |
$30.71
|
| Rate for Payer: Anthem Medicare Advantage |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.71
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$443.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$233.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.71
|
| Rate for Payer: Health EOS Commercial |
$424.93
|
| Rate for Payer: HFN Commercial |
$443.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.71
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: NAPHCARE Commercial |
$46.07
|
| Rate for Payer: Preferred Network Access Commercial |
$443.61
|
| Rate for Payer: Quartz Beloit One Network |
$205.46
|
| Rate for Payer: Quartz Commercial |
$266.17
|
| Rate for Payer: Quartz Medicare Advantage |
$30.71
|
| Rate for Payer: The Alliance Commercial |
$121.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.71
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: WPS Commercial |
$135.13
|
|
|
Histamine
|
Facility
|
IP
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$228.81 |
| Max. Negotiated Rate |
$429.60 |
| Rate for Payer: Aetna Commercial |
$420.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.49
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$429.60
|
| Rate for Payer: Health EOS Commercial |
$415.59
|
| Rate for Payer: HFN Commercial |
$429.60
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: Preferred Network Access Commercial |
$429.60
|
| Rate for Payer: Quartz Beloit One Network |
$228.81
|
| Rate for Payer: Quartz Commercial |
$280.18
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: WPS Commercial |
$345.86
|
|
|
Histamine
|
Facility
|
OP
|
$449.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
977977
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$429.60 |
| Rate for Payer: Aetna Commercial |
$420.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Aetna Managed Medicare |
$30.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.98
|
| Rate for Payer: Anthem Medicare Advantage |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.71
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$429.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$261.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.71
|
| Rate for Payer: Health EOS Commercial |
$415.59
|
| Rate for Payer: HFN Commercial |
$429.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.71
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: NAPHCARE Commercial |
$46.07
|
| Rate for Payer: Preferred Network Access Commercial |
$429.60
|
| Rate for Payer: Quartz Beloit One Network |
$228.81
|
| Rate for Payer: Quartz Commercial |
$303.52
|
| Rate for Payer: Quartz Medicare Advantage |
$30.71
|
| Rate for Payer: The Alliance Commercial |
$122.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.71
|
| Rate for Payer: United Healthcare PPO |
$350.22
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: Wellcare Medicare |
$30.71
|
| Rate for Payer: WPS Commercial |
$345.86
|
|
|
Histamine 24 Hour Urine
|
Facility
|
IP
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$151.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.29
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$155.00
|
| Rate for Payer: Health EOS Commercial |
$149.95
|
| Rate for Payer: HFN Commercial |
$155.00
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: Preferred Network Access Commercial |
$155.00
|
| Rate for Payer: Quartz Beloit One Network |
$82.56
|
| Rate for Payer: Quartz Commercial |
$101.09
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: WPS Commercial |
$124.79
|
|
|
Histamine 24 Hour Urine
|
Facility
|
OP
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$155.00 |
| Rate for Payer: Aetna Commercial |
$151.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Aetna Managed Medicare |
$30.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$115.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.74
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.98
|
| Rate for Payer: Anthem Medicare Advantage |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.71
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$155.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.28
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.71
|
| Rate for Payer: Health EOS Commercial |
$149.95
|
| Rate for Payer: HFN Commercial |
$155.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.71
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: NAPHCARE Commercial |
$46.07
|
| Rate for Payer: Preferred Network Access Commercial |
$155.00
|
| Rate for Payer: Quartz Beloit One Network |
$82.56
|
| Rate for Payer: Quartz Commercial |
$109.51
|
| Rate for Payer: Quartz Medicare Advantage |
$30.71
|
| Rate for Payer: The Alliance Commercial |
$122.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.71
|
| Rate for Payer: United Healthcare PPO |
$126.36
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: Wellcare Medicare |
$30.71
|
| Rate for Payer: WPS Commercial |
$124.79
|
|
|
Histamine 24 Hour Urine
|
Professional
|
Both
|
$162.00
|
|
|
Service Code
|
CPT 83088
|
| Hospital Charge Code |
4538880
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.71 |
| Max. Negotiated Rate |
$160.06 |
| Rate for Payer: Aetna Commercial |
$160.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$144.89
|
| Rate for Payer: Aetna Managed Medicare |
$30.71
|
| Rate for Payer: Anthem Medicare Advantage |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.71
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cash Price |
$48.60
|
| Rate for Payer: Cigna Commercial |
$160.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$84.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.71
|
| Rate for Payer: Health EOS Commercial |
$153.32
|
| Rate for Payer: HFN Commercial |
$160.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.41
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.71
|
| Rate for Payer: Multiplan Commercial |
$134.78
|
| Rate for Payer: NAPHCARE Commercial |
$46.07
|
| Rate for Payer: Preferred Network Access Commercial |
$160.06
|
| Rate for Payer: Quartz Beloit One Network |
$74.13
|
| Rate for Payer: Quartz Commercial |
$96.03
|
| Rate for Payer: Quartz Medicare Advantage |
$30.71
|
| Rate for Payer: The Alliance Commercial |
$121.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.71
|
| Rate for Payer: WEA Trust Commercial |
$92.66
|
| Rate for Payer: WPS Commercial |
$135.13
|
|
|
Histone Ab / 37056
|
Facility
|
OP
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$47.96 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$44.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$20.98
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$19.91
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24.44
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$28.39
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: United Healthcare PPO |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: Wellcare Medicare |
$11.99
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
Histone Ab / 37056
|
Facility
|
IP
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.40 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna Commercial |
$39.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.15
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$40.19
|
| Rate for Payer: Health EOS Commercial |
$38.88
|
| Rate for Payer: HFN Commercial |
$40.19
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: Preferred Network Access Commercial |
$40.19
|
| Rate for Payer: Quartz Beloit One Network |
$21.40
|
| Rate for Payer: Quartz Commercial |
$26.21
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$32.35
|
|
|
Histone Ab / 37056
|
Professional
|
Both
|
$42.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
4075715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$52.76 |
| Rate for Payer: Aetna Commercial |
$41.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$37.56
|
| Rate for Payer: Aetna Managed Medicare |
$11.99
|
| Rate for Payer: Anthem Medicare Advantage |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11.99
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cigna Commercial |
$41.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.99
|
| Rate for Payer: Health EOS Commercial |
$39.75
|
| Rate for Payer: HFN Commercial |
$41.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11.99
|
| Rate for Payer: Multiplan Commercial |
$34.94
|
| Rate for Payer: NAPHCARE Commercial |
$17.99
|
| Rate for Payer: Preferred Network Access Commercial |
$41.50
|
| Rate for Payer: Quartz Beloit One Network |
$19.22
|
| Rate for Payer: Quartz Commercial |
$24.90
|
| Rate for Payer: Quartz Medicare Advantage |
$11.99
|
| Rate for Payer: The Alliance Commercial |
$47.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11.99
|
| Rate for Payer: WEA Trust Commercial |
$24.02
|
| Rate for Payer: WPS Commercial |
$52.76
|
|
|
Histoplasma Antibody
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
5598647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.05 |
| Max. Negotiated Rate |
$54.54 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$35.57
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
|
Histoplasma Antibody
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
977978
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.44 |
| Max. Negotiated Rate |
$143.52 |
| Rate for Payer: Aetna Commercial |
$140.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$82.68
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$143.52
|
| Rate for Payer: Health EOS Commercial |
$138.84
|
| Rate for Payer: HFN Commercial |
$143.52
|
| Rate for Payer: Multiplan Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.52
|
| Rate for Payer: Quartz Beloit One Network |
$76.44
|
| Rate for Payer: Quartz Commercial |
$93.60
|
| Rate for Payer: WEA Trust Commercial |
$85.80
|
| Rate for Payer: WPS Commercial |
$115.55
|
|
|
Histoplasma Antibody
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
CPT 86698
|
| Hospital Charge Code |
5598647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.34 |
| Max. Negotiated Rate |
$57.37 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.98
|
| Rate for Payer: Aetna Managed Medicare |
$14.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.81
|
| Rate for Payer: Anthem Medicare Advantage |
$14.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.34
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cash Price |
$17.10
|
| Rate for Payer: Cigna Commercial |
$54.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.17
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.34
|
| Rate for Payer: Health EOS Commercial |
$52.76
|
| Rate for Payer: HFN Commercial |
$54.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.34
|
| Rate for Payer: Multiplan Commercial |
$47.42
|
| Rate for Payer: NAPHCARE Commercial |
$21.51
|
| Rate for Payer: Preferred Network Access Commercial |
$54.54
|
| Rate for Payer: Quartz Beloit One Network |
$29.05
|
| Rate for Payer: Quartz Commercial |
$38.53
|
| Rate for Payer: Quartz Medicare Advantage |
$14.34
|
| Rate for Payer: The Alliance Commercial |
$57.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.34
|
| Rate for Payer: United Healthcare PPO |
$44.46
|
| Rate for Payer: WEA Trust Commercial |
$32.60
|
| Rate for Payer: Wellcare Medicare |
$14.34
|
| Rate for Payer: WPS Commercial |
$43.91
|
|
