|
JAGWIRE GUIDEWIRE STR .025 450CM M00556561
|
Facility
|
OP
|
$1,712.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.36 |
| Max. Negotiated Rate |
$6,848.00 |
| Rate for Payer: Aetna Commercial |
$1,540.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,472.32
|
| Rate for Payer: Aetna Managed Medicare |
$479.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,112.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$856.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$821.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$907.36
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$1,575.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$958.04
|
| Rate for Payer: Health EOS Commercial |
$1,523.68
|
| Rate for Payer: HFN Commercial |
$1,575.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,284.00
|
| Rate for Payer: Multiplan Commercial |
$1,369.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,027.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,575.04
|
| Rate for Payer: Quartz Beloit One Network |
$838.88
|
| Rate for Payer: Quartz Commercial |
$1,112.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,027.20
|
| Rate for Payer: The Alliance Commercial |
$6,848.00
|
| Rate for Payer: WEA Trust Commercial |
$941.60
|
| Rate for Payer: WPS Commercial |
$1,268.08
|
|
|
JAGWIRE GUIDEWIRE STR .025 450CM M00556561
|
Facility
|
IP
|
$1,712.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
2973105
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$838.88 |
| Max. Negotiated Rate |
$1,575.04 |
| Rate for Payer: Aetna Commercial |
$1,540.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,472.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$907.36
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna Commercial |
$1,575.04
|
| Rate for Payer: Health EOS Commercial |
$1,523.68
|
| Rate for Payer: HFN Commercial |
$1,575.04
|
| Rate for Payer: Multiplan Commercial |
$1,369.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,027.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,575.04
|
| Rate for Payer: Quartz Beloit One Network |
$838.88
|
| Rate for Payer: Quartz Commercial |
$1,027.20
|
| Rate for Payer: WEA Trust Commercial |
$941.60
|
| Rate for Payer: WPS Commercial |
$1,268.08
|
|
|
JAK2 Exon 12 Mutations
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2942930
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
JAK2 Exon 12 Mutations
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2942930
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
JAK2 Exon 12 Mutations
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2942930
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: United Healthcare PPO |
$213.75
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Jak2 Interp & Report
|
Professional
|
Both
|
$60.00
|
|
| Hospital Charge Code |
2776830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.40 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$57.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.00
|
| Rate for Payer: Health EOS Commercial |
$54.60
|
| Rate for Payer: HFN Commercial |
$57.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: Preferred Network Access Commercial |
$57.00
|
| Rate for Payer: Quartz Beloit One Network |
$26.40
|
| Rate for Payer: Quartz Commercial |
$34.20
|
| Rate for Payer: The Alliance Commercial |
$30.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Jak2 Interp & Report
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
2776830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Aetna Managed Medicare |
$16.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.58
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$39.00
|
| Rate for Payer: Quartz Medicare Advantage |
$36.00
|
| Rate for Payer: The Alliance Commercial |
$240.00
|
| Rate for Payer: United Healthcare PPO |
$45.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Jak2 Interp & Report
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
2776830
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$55.20 |
| Rate for Payer: Aetna Commercial |
$54.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.80
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: Health EOS Commercial |
$53.40
|
| Rate for Payer: HFN Commercial |
$55.20
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.00
|
| Rate for Payer: Preferred Network Access Commercial |
$55.20
|
| Rate for Payer: Quartz Beloit One Network |
$29.40
|
| Rate for Payer: Quartz Commercial |
$36.00
|
| Rate for Payer: WEA Trust Commercial |
$33.00
|
| Rate for Payer: WPS Commercial |
$44.44
|
|
|
Jak2 Separation
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Jak2 Separation
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Jak2 Separation
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776831
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
JAK2 V617F Mutation, Quantitative
|
Professional
|
Both
|
$1,219.00
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
5313603
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$323.56 |
| Max. Negotiated Rate |
$1,158.05 |
| Rate for Payer: Aetna Commercial |
$1,158.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,048.34
|
| Rate for Payer: Cash Price |
$365.70
|
| Rate for Payer: Cash Price |
$365.70
|
| Rate for Payer: Cigna Commercial |
$1,158.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$609.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$731.40
|
| Rate for Payer: Health EOS Commercial |
$1,109.29
|
| Rate for Payer: HFN Commercial |
$1,158.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$323.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$323.56
|
| Rate for Payer: Multiplan Commercial |
$975.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,158.05
|
| Rate for Payer: Quartz Beloit One Network |
$536.36
|
| Rate for Payer: Quartz Commercial |
$694.83
|
| Rate for Payer: The Alliance Commercial |
$609.50
|
| Rate for Payer: WEA Trust Commercial |
$670.45
|
| Rate for Payer: WPS Commercial |
$902.91
|
|
|
JAK2 V617F Mutation, Quantitative
|
Facility
|
OP
|
$1,219.00
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
5313603
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.66 |
| Max. Negotiated Rate |
$1,121.48 |
| Rate for Payer: Aetna Commercial |
$1,097.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,048.34
|
| Rate for Payer: Aetna Managed Medicare |
$91.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$343.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$160.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$152.16
|
| Rate for Payer: Anthem Medicaid |
$94.71
|
| Rate for Payer: Anthem Medicare Advantage |
$91.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$646.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$91.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$91.66
|
| Rate for Payer: Cash Price |
$365.70
|
| Rate for Payer: Cash Price |
$365.70
|
| Rate for Payer: Cigna Commercial |
$1,121.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$91.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$682.15
|
| Rate for Payer: Dean Health Medicaid |
$94.71
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$91.66
|
| Rate for Payer: Health EOS Commercial |
$1,084.91
|
| Rate for Payer: HFN Commercial |
$1,121.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$340.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$91.66
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$94.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$91.66
|
| Rate for Payer: Managed Health Services Medicaid |
$98.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$91.66
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$91.66
|
| Rate for Payer: Multiplan Commercial |
$975.20
|
| Rate for Payer: NAPHCARE Commercial |
$137.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,121.48
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$94.71
|
| Rate for Payer: Quartz Beloit One Network |
$597.31
|
| Rate for Payer: Quartz Commercial |
$792.35
|
| Rate for Payer: Quartz Medicare Advantage |
$91.66
|
| Rate for Payer: The Alliance Commercial |
$366.64
|
| Rate for Payer: United Healthcare Medicaid |
$94.71
|
| Rate for Payer: United Healthcare Medicare Advantage |
$91.66
|
| Rate for Payer: United Healthcare PPO |
$914.25
|
| Rate for Payer: WEA Trust Commercial |
$670.45
|
| Rate for Payer: Wellcare Medicare |
$91.66
|
| Rate for Payer: WMAP Medicaid |
$94.71
|
| Rate for Payer: WPS Commercial |
$902.91
|
|
|
JAK2 V617F Mutation, Quantitative
|
Facility
|
IP
|
$1,219.00
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
5313603
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$597.31 |
| Max. Negotiated Rate |
$1,121.48 |
| Rate for Payer: Aetna Commercial |
$1,097.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,048.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$646.07
|
| Rate for Payer: Cash Price |
$365.70
|
| Rate for Payer: Cigna Commercial |
$1,121.48
|
| Rate for Payer: Health EOS Commercial |
$1,084.91
|
| Rate for Payer: HFN Commercial |
$1,121.48
|
| Rate for Payer: Multiplan Commercial |
$975.20
|
| Rate for Payer: NAPHCARE Commercial |
$731.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,121.48
|
| Rate for Payer: Quartz Beloit One Network |
$597.31
|
| Rate for Payer: Quartz Commercial |
$731.40
|
| Rate for Payer: WEA Trust Commercial |
$670.45
|
| Rate for Payer: WPS Commercial |
$902.91
|
|
|
Januvia 1 mg Charge
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
2958864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$95.92 |
| Max. Negotiated Rate |
$529.39 |
| Rate for Payer: Aetna Commercial |
$207.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$207.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$210.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$211.76
|
| Rate for Payer: Health EOS Commercial |
$198.38
|
| Rate for Payer: HFN Commercial |
$207.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$268.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$268.73
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: Preferred Network Access Commercial |
$207.10
|
| Rate for Payer: Quartz Beloit One Network |
$95.92
|
| Rate for Payer: Quartz Commercial |
$124.26
|
| Rate for Payer: The Alliance Commercial |
$109.00
|
| Rate for Payer: United Healthcare Medicaid |
$210.45
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: WPS Commercial |
$529.39
|
|
|
Januvia 1 mg Charge
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
2958864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$104.64 |
| Max. Negotiated Rate |
$841.81 |
| Rate for Payer: Aetna Commercial |
$196.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Aetna Managed Medicare |
$210.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$141.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$109.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.64
|
| Rate for Payer: Anthem Medicare Advantage |
$210.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$210.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$210.45
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$200.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$210.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$280.15
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$210.45
|
| Rate for Payer: Health EOS Commercial |
$194.02
|
| Rate for Payer: HFN Commercial |
$200.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$782.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$210.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$210.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$210.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$210.45
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: NAPHCARE Commercial |
$315.68
|
| Rate for Payer: Preferred Network Access Commercial |
$200.56
|
| Rate for Payer: Quartz Beloit One Network |
$106.82
|
| Rate for Payer: Quartz Commercial |
$141.70
|
| Rate for Payer: Quartz Medicare Advantage |
$210.45
|
| Rate for Payer: The Alliance Commercial |
$841.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$210.45
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: Wellcare Medicare |
$210.45
|
| Rate for Payer: WPS Commercial |
$529.39
|
|
|
Januvia 1 mg Charge
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
2958864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.82 |
| Max. Negotiated Rate |
$200.56 |
| Rate for Payer: Aetna Commercial |
$196.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$187.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$115.54
|
| Rate for Payer: Cash Price |
$65.40
|
| Rate for Payer: Cigna Commercial |
$200.56
|
| Rate for Payer: Health EOS Commercial |
$194.02
|
| Rate for Payer: HFN Commercial |
$200.56
|
| Rate for Payer: Multiplan Commercial |
$174.40
|
| Rate for Payer: NAPHCARE Commercial |
$130.80
|
| Rate for Payer: Preferred Network Access Commercial |
$200.56
|
| Rate for Payer: Quartz Beloit One Network |
$106.82
|
| Rate for Payer: Quartz Commercial |
$130.80
|
| Rate for Payer: WEA Trust Commercial |
$119.90
|
| Rate for Payer: WPS Commercial |
$161.47
|
|
|
Jaundice evaluation with lab ordered - Outpatient Newborn Follow-Up Charges
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5356649
|
|
Hospital Revenue Code
|
514
|
| Min. Negotiated Rate |
$95.06 |
| Max. Negotiated Rate |
$178.48 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$116.40
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
Jaundice evaluation with lab ordered - Outpatient Newborn Follow-Up Charges
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
5356649
|
|
Hospital Revenue Code
|
514
|
| Min. Negotiated Rate |
$54.32 |
| Max. Negotiated Rate |
$776.00 |
| Rate for Payer: Aetna Commercial |
$174.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$166.84
|
| Rate for Payer: Aetna Managed Medicare |
$54.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$126.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$93.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.82
|
| Rate for Payer: Cash Price |
$58.20
|
| Rate for Payer: Cigna Commercial |
$178.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$172.66
|
| Rate for Payer: HFN Commercial |
$178.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$145.50
|
| Rate for Payer: Multiplan Commercial |
$155.20
|
| Rate for Payer: NAPHCARE Commercial |
$116.40
|
| Rate for Payer: Preferred Network Access Commercial |
$178.48
|
| Rate for Payer: Quartz Beloit One Network |
$95.06
|
| Rate for Payer: Quartz Commercial |
$126.10
|
| Rate for Payer: Quartz Medicare Advantage |
$116.40
|
| Rate for Payer: The Alliance Commercial |
$776.00
|
| Rate for Payer: WEA Trust Commercial |
$106.70
|
| Rate for Payer: WPS Commercial |
$143.70
|
|
|
JAW BRA FACIAL SUPPORT 91
|
Facility
|
OP
|
$480.00
|
|
| Hospital Charge Code |
2963738
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Aetna Managed Medicare |
$134.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$312.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$240.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$230.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$268.61
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$360.00
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$312.00
|
| Rate for Payer: Quartz Medicare Advantage |
$288.00
|
| Rate for Payer: The Alliance Commercial |
$1,920.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
JAW BRA FACIAL SUPPORT 91
|
Facility
|
IP
|
$480.00
|
|
| Hospital Charge Code |
2963738
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.20 |
| Max. Negotiated Rate |
$441.60 |
| Rate for Payer: Aetna Commercial |
$432.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$412.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$254.40
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$441.60
|
| Rate for Payer: Health EOS Commercial |
$427.20
|
| Rate for Payer: HFN Commercial |
$441.60
|
| Rate for Payer: Multiplan Commercial |
$384.00
|
| Rate for Payer: NAPHCARE Commercial |
$288.00
|
| Rate for Payer: Preferred Network Access Commercial |
$441.60
|
| Rate for Payer: Quartz Beloit One Network |
$235.20
|
| Rate for Payer: Quartz Commercial |
$288.00
|
| Rate for Payer: WEA Trust Commercial |
$264.00
|
| Rate for Payer: WPS Commercial |
$355.54
|
|
|
JAW SUBLUXATION
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960395
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$281.68 |
| Max. Negotiated Rate |
$4,024.00 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Aetna Managed Medicare |
$281.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$653.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$503.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$482.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$562.96
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.50
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$653.90
|
| Rate for Payer: Quartz Medicare Advantage |
$603.60
|
| Rate for Payer: The Alliance Commercial |
$4,024.00
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
JAW SUBLUXATION
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960395
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$492.94 |
| Max. Negotiated Rate |
$925.52 |
| Rate for Payer: Aetna Commercial |
$905.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$865.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$533.18
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$925.52
|
| Rate for Payer: Health EOS Commercial |
$895.34
|
| Rate for Payer: HFN Commercial |
$925.52
|
| Rate for Payer: Multiplan Commercial |
$804.80
|
| Rate for Payer: NAPHCARE Commercial |
$603.60
|
| Rate for Payer: Preferred Network Access Commercial |
$925.52
|
| Rate for Payer: Quartz Beloit One Network |
$492.94
|
| Rate for Payer: Quartz Commercial |
$603.60
|
| Rate for Payer: WEA Trust Commercial |
$553.30
|
| Rate for Payer: WPS Commercial |
$745.14
|
|
|
JAW WIRE 24 GA 200-662
|
Facility
|
OP
|
$614.00
|
|
| Hospital Charge Code |
2965100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$171.92 |
| Max. Negotiated Rate |
$2,456.00 |
| Rate for Payer: Aetna Commercial |
$552.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.04
|
| Rate for Payer: Aetna Managed Medicare |
$171.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$399.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$307.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$294.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.42
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$564.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$343.59
|
| Rate for Payer: Health EOS Commercial |
$546.46
|
| Rate for Payer: HFN Commercial |
$564.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$460.50
|
| Rate for Payer: Multiplan Commercial |
$491.20
|
| Rate for Payer: NAPHCARE Commercial |
$368.40
|
| Rate for Payer: Preferred Network Access Commercial |
$564.88
|
| Rate for Payer: Quartz Beloit One Network |
$300.86
|
| Rate for Payer: Quartz Commercial |
$399.10
|
| Rate for Payer: Quartz Medicare Advantage |
$368.40
|
| Rate for Payer: The Alliance Commercial |
$2,456.00
|
| Rate for Payer: WEA Trust Commercial |
$337.70
|
| Rate for Payer: WPS Commercial |
$454.79
|
|
|
JAW WIRE 24 GA 200-662
|
Facility
|
IP
|
$614.00
|
|
| Hospital Charge Code |
2965100
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$300.86 |
| Max. Negotiated Rate |
$564.88 |
| Rate for Payer: Aetna Commercial |
$552.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$528.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$325.42
|
| Rate for Payer: Cash Price |
$184.20
|
| Rate for Payer: Cigna Commercial |
$564.88
|
| Rate for Payer: Health EOS Commercial |
$546.46
|
| Rate for Payer: HFN Commercial |
$564.88
|
| Rate for Payer: Multiplan Commercial |
$491.20
|
| Rate for Payer: NAPHCARE Commercial |
$368.40
|
| Rate for Payer: Preferred Network Access Commercial |
$564.88
|
| Rate for Payer: Quartz Beloit One Network |
$300.86
|
| Rate for Payer: Quartz Commercial |
$368.40
|
| Rate for Payer: WEA Trust Commercial |
$337.70
|
| Rate for Payer: WPS Commercial |
$454.79
|
|
