|
21-Hydroxylase Antibody
|
Facility
IP
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$100.94 |
| Max. Negotiated Rate |
$189.52 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$123.60
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$123.60
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
21-Hydroxylase Antibody
|
Professional
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$195.70 |
| Rate for Payer: Aetna Commercial |
$195.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Aetna Managed Medicare |
$18.40
|
| Rate for Payer: Anthem Medicare Advantage |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.40
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$195.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$103.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$187.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$64.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: Preferred Network Access Commercial |
$195.70
|
| Rate for Payer: Quartz Beloit One Network |
$90.64
|
| Rate for Payer: Quartz Commercial |
$117.42
|
| Rate for Payer: Quartz Medicare Advantage |
$18.40
|
| Rate for Payer: The Alliance Commercial |
$72.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.40
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: WPS Commercial |
$80.96
|
|
|
21-Hydroxylase Antibody
|
Facility
OP
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.40 |
| Max. Negotiated Rate |
$824.00 |
| Rate for Payer: Aetna Commercial |
$185.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$177.16
|
| Rate for Payer: Aetna Managed Medicare |
$18.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.54
|
| Rate for Payer: Anthem Medicaid |
$19.00
|
| Rate for Payer: Anthem Medicare Advantage |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$109.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.40
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$189.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.00
|
| Rate for Payer: Dean Health Medicaid |
$19.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$183.34
|
| Rate for Payer: HFN Commercial |
$189.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.40
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.40
|
| Rate for Payer: Managed Health Services Medicaid |
$19.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$164.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.60
|
| Rate for Payer: Preferred Network Access Commercial |
$189.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$100.94
|
| Rate for Payer: Quartz Commercial |
$133.90
|
| Rate for Payer: Quartz Medicare Advantage |
$18.40
|
| Rate for Payer: The Alliance Commercial |
$824.00
|
| Rate for Payer: United Healthcare Medicaid |
$19.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.40
|
| Rate for Payer: United Healthcare PPO |
$154.50
|
| Rate for Payer: WEA Trust Commercial |
$113.30
|
| Rate for Payer: Wellcare Medicare |
$18.40
|
| Rate for Payer: WMAP Medicaid |
$19.00
|
| Rate for Payer: WPS Commercial |
$152.58
|
|
|
2:1 Nursing Daily - Devices and Equipment
|
Facility
IP
|
$2,073.00
|
|
| Hospital Charge Code |
3002387
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$1,015.77 |
| Max. Negotiated Rate |
$1,907.16 |
| Rate for Payer: Aetna Commercial |
$1,865.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,098.69
|
| Rate for Payer: Cash Price |
$621.90
|
| Rate for Payer: Cigna Commercial |
$1,907.16
|
| Rate for Payer: Health EOS Commercial |
$1,844.97
|
| Rate for Payer: HFN Commercial |
$1,907.16
|
| Rate for Payer: Multiplan Commercial |
$1,658.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,243.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,907.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,015.77
|
| Rate for Payer: Quartz Commercial |
$1,243.80
|
| Rate for Payer: WEA Trust Commercial |
$1,140.15
|
| Rate for Payer: WPS Commercial |
$1,535.47
|
|
|
2:1 Nursing Daily - Devices and Equipment
|
Facility
OP
|
$2,073.00
|
|
| Hospital Charge Code |
3002387
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$580.44 |
| Max. Negotiated Rate |
$8,292.00 |
| Rate for Payer: Aetna Commercial |
$1,865.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,782.78
|
| Rate for Payer: Aetna Managed Medicare |
$580.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,347.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,036.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$995.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,098.69
|
| Rate for Payer: Cash Price |
$621.90
|
| Rate for Payer: Cigna Commercial |
$1,907.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,160.05
|
| Rate for Payer: Health EOS Commercial |
$1,844.97
|
| Rate for Payer: HFN Commercial |
$1,907.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,554.75
|
| Rate for Payer: Multiplan Commercial |
$1,658.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,243.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,907.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,015.77
|
| Rate for Payer: Quartz Commercial |
$1,347.45
|
| Rate for Payer: Quartz Medicare Advantage |
$1,243.80
|
| Rate for Payer: The Alliance Commercial |
$8,292.00
|
| Rate for Payer: WEA Trust Commercial |
$1,140.15
|
| Rate for Payer: WPS Commercial |
$1,535.47
|
|
|
22 - Catheter size
|
Facility
IP
|
$93.00
|
|
| Hospital Charge Code |
2999972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
22 - Catheter size
|
Facility
OP
|
$93.00
|
|
| Hospital Charge Code |
2999972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
22 G 1*6231""
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
3040302
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
22 G 1*6231""
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
3040302
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
2,3-Dinor 11 Beta-Prostaglandin F2 Alpha, Urine
|
Facility
OP
|
$676.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5841647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$2,704.00 |
| Rate for Payer: Aetna Commercial |
$608.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$581.36
|
| Rate for Payer: Aetna Managed Medicare |
$41.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.34
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.77
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$621.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$41.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.09
|
| Rate for Payer: Dean Health Medicaid |
$35.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$41.77
|
| Rate for Payer: Health EOS Commercial |
$601.64
|
| Rate for Payer: HFN Commercial |
$621.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.77
|
| Rate for Payer: Managed Health Services Medicaid |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$41.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$41.77
|
| Rate for Payer: Multiplan Commercial |
$540.80
|
| Rate for Payer: NAPHCARE Commercial |
$62.66
|
| Rate for Payer: Preferred Network Access Commercial |
$621.92
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$35.09
|
| Rate for Payer: Quartz Beloit One Network |
$331.24
|
| Rate for Payer: Quartz Commercial |
$439.40
|
| Rate for Payer: Quartz Medicare Advantage |
$41.77
|
| Rate for Payer: The Alliance Commercial |
$2,704.00
|
| Rate for Payer: United Healthcare Medicaid |
$35.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.77
|
| Rate for Payer: United Healthcare PPO |
$507.00
|
| Rate for Payer: WEA Trust Commercial |
$371.80
|
| Rate for Payer: Wellcare Medicare |
$41.77
|
| Rate for Payer: WMAP Medicaid |
$35.09
|
| Rate for Payer: WPS Commercial |
$500.71
|
|
|
2,3-Dinor 11 Beta-Prostaglandin F2 Alpha, Urine
|
Professional
|
$676.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5841647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$41.77 |
| Max. Negotiated Rate |
$642.20 |
| Rate for Payer: Aetna Commercial |
$642.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$581.36
|
| Rate for Payer: Aetna Managed Medicare |
$41.77
|
| Rate for Payer: Anthem Medicare Advantage |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.77
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$642.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$338.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.77
|
| Rate for Payer: Health EOS Commercial |
$615.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.45
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$147.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.77
|
| Rate for Payer: Multiplan Commercial |
$540.80
|
| Rate for Payer: Preferred Network Access Commercial |
$642.20
|
| Rate for Payer: Quartz Beloit One Network |
$297.44
|
| Rate for Payer: Quartz Commercial |
$385.32
|
| Rate for Payer: Quartz Medicare Advantage |
$41.77
|
| Rate for Payer: The Alliance Commercial |
$164.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.77
|
| Rate for Payer: WEA Trust Commercial |
$371.80
|
| Rate for Payer: WPS Commercial |
$183.79
|
|
|
2,3-Dinor 11 Beta-Prostaglandin F2 Alpha, Urine
|
Facility
IP
|
$676.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5841647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$331.24 |
| Max. Negotiated Rate |
$621.92 |
| Rate for Payer: Aetna Commercial |
$608.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$358.28
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$621.92
|
| Rate for Payer: Health EOS Commercial |
$601.64
|
| Rate for Payer: HFN Commercial |
$621.92
|
| Rate for Payer: Multiplan Commercial |
$540.80
|
| Rate for Payer: NAPHCARE Commercial |
$405.60
|
| Rate for Payer: Preferred Network Access Commercial |
$621.92
|
| Rate for Payer: Quartz Beloit One Network |
$331.24
|
| Rate for Payer: Quartz Commercial |
$405.60
|
| Rate for Payer: WEA Trust Commercial |
$371.80
|
| Rate for Payer: WPS Commercial |
$500.71
|
|
|
240 mg - Firmagon Charge
|
Facility
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$5,962.40 |
| Rate for Payer: Aetna Commercial |
$673.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.28
|
| Rate for Payer: Aetna Managed Medicare |
$4.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$374.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$359.04
|
| Rate for Payer: Anthem Medicare Advantage |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.19
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$688.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.19
|
| Rate for Payer: Health EOS Commercial |
$665.72
|
| Rate for Payer: HFN Commercial |
$688.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: NAPHCARE Commercial |
$6.28
|
| Rate for Payer: Preferred Network Access Commercial |
$688.16
|
| Rate for Payer: Quartz Beloit One Network |
$366.52
|
| Rate for Payer: Quartz Commercial |
$486.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.19
|
| Rate for Payer: The Alliance Commercial |
$5,962.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.19
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: Wellcare Medicare |
$4.19
|
| Rate for Payer: WPS Commercial |
$10.88
|
|
|
240 mg - Firmagon Charge
|
Professional
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$710.60 |
| Rate for Payer: Aetna Commercial |
$710.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.28
|
| Rate for Payer: Aetna Managed Medicare |
$4.19
|
| Rate for Payer: Anthem Medicare Advantage |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.19
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$710.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$374.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.35
|
| Rate for Payer: Health EOS Commercial |
$680.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: Preferred Network Access Commercial |
$710.60
|
| Rate for Payer: Quartz Beloit One Network |
$329.12
|
| Rate for Payer: Quartz Commercial |
$426.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4.19
|
| Rate for Payer: The Alliance Commercial |
$11.53
|
| Rate for Payer: United Healthcare Medicaid |
$4.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.19
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: WPS Commercial |
$10.88
|
|
|
240 mg - Firmagon Charge
|
Facility
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$366.52 |
| Max. Negotiated Rate |
$688.16 |
| Rate for Payer: Aetna Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.44
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$688.16
|
| Rate for Payer: Health EOS Commercial |
$665.72
|
| Rate for Payer: HFN Commercial |
$688.16
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: NAPHCARE Commercial |
$448.80
|
| Rate for Payer: Preferred Network Access Commercial |
$688.16
|
| Rate for Payer: Quartz Beloit One Network |
$366.52
|
| Rate for Payer: Quartz Commercial |
$448.80
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: WPS Commercial |
$554.04
|
|
|
24 - Catheter size
|
Facility
OP
|
$93.00
|
|
| Hospital Charge Code |
2999971
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
24 - Catheter size
|
Facility
IP
|
$93.00
|
|
| Hospital Charge Code |
2999971
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
24 G 1.25
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
3040303
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.44
|
| Rate for Payer: Aetna Managed Medicare |
$1.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.24
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2.40
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
24 G 1.25
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
3040303
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.12
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: Health EOS Commercial |
$3.56
|
| Rate for Payer: HFN Commercial |
$3.68
|
| Rate for Payer: Multiplan Commercial |
$3.20
|
| Rate for Payer: NAPHCARE Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3.68
|
| Rate for Payer: Quartz Beloit One Network |
$1.96
|
| Rate for Payer: Quartz Commercial |
$2.40
|
| Rate for Payer: WEA Trust Commercial |
$2.20
|
| Rate for Payer: WPS Commercial |
$2.96
|
|
|
2.5 Hours - Respiratory Therapy Treatment Duration
|
Facility
IP
|
$1,289.00
|
|
| Hospital Charge Code |
3023873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$631.61 |
| Max. Negotiated Rate |
$1,185.88 |
| Rate for Payer: Aetna Commercial |
$1,160.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$683.17
|
| Rate for Payer: Cash Price |
$386.70
|
| Rate for Payer: Cigna Commercial |
$1,185.88
|
| Rate for Payer: Health EOS Commercial |
$1,147.21
|
| Rate for Payer: HFN Commercial |
$1,185.88
|
| Rate for Payer: Multiplan Commercial |
$1,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$773.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,185.88
|
| Rate for Payer: Quartz Beloit One Network |
$631.61
|
| Rate for Payer: Quartz Commercial |
$773.40
|
| Rate for Payer: WEA Trust Commercial |
$708.95
|
| Rate for Payer: WPS Commercial |
$954.76
|
|
|
2.5 Hours - Respiratory Therapy Treatment Duration
|
Facility
OP
|
$1,289.00
|
|
| Hospital Charge Code |
3023873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$360.92 |
| Max. Negotiated Rate |
$5,156.00 |
| Rate for Payer: Aetna Commercial |
$1,160.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,108.54
|
| Rate for Payer: Aetna Managed Medicare |
$360.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$837.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$644.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$618.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$683.17
|
| Rate for Payer: Cash Price |
$386.70
|
| Rate for Payer: Cigna Commercial |
$1,185.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$721.32
|
| Rate for Payer: Health EOS Commercial |
$1,147.21
|
| Rate for Payer: HFN Commercial |
$1,185.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$966.75
|
| Rate for Payer: Multiplan Commercial |
$1,031.20
|
| Rate for Payer: NAPHCARE Commercial |
$773.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,185.88
|
| Rate for Payer: Quartz Beloit One Network |
$631.61
|
| Rate for Payer: Quartz Commercial |
$837.85
|
| Rate for Payer: Quartz Medicare Advantage |
$773.40
|
| Rate for Payer: The Alliance Commercial |
$5,156.00
|
| Rate for Payer: WEA Trust Commercial |
$708.95
|
| Rate for Payer: WPS Commercial |
$954.76
|
|
|
272 STERILE SUPPLY
|
Facility
IP
|
$7,738.00
|
|
| Hospital Charge Code |
3054515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,791.62 |
| Max. Negotiated Rate |
$7,118.96 |
| Rate for Payer: Aetna Commercial |
$6,964.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,101.14
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,118.96
|
| Rate for Payer: Health EOS Commercial |
$6,886.82
|
| Rate for Payer: HFN Commercial |
$7,118.96
|
| Rate for Payer: Multiplan Commercial |
$6,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,642.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,118.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,791.62
|
| Rate for Payer: Quartz Commercial |
$4,642.80
|
| Rate for Payer: WEA Trust Commercial |
$4,255.90
|
| Rate for Payer: WPS Commercial |
$5,731.54
|
|
|
272 STERILE SUPPLY
|
Facility
OP
|
$7,738.00
|
|
| Hospital Charge Code |
3054515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,166.64 |
| Max. Negotiated Rate |
$30,952.00 |
| Rate for Payer: Aetna Commercial |
$6,964.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,654.68
|
| Rate for Payer: Aetna Managed Medicare |
$2,166.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,029.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,869.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,714.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,101.14
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,118.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,330.18
|
| Rate for Payer: Health EOS Commercial |
$6,886.82
|
| Rate for Payer: HFN Commercial |
$7,118.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,803.50
|
| Rate for Payer: Multiplan Commercial |
$6,190.40
|
| Rate for Payer: NAPHCARE Commercial |
$4,642.80
|
| Rate for Payer: Preferred Network Access Commercial |
$7,118.96
|
| Rate for Payer: Quartz Beloit One Network |
$3,791.62
|
| Rate for Payer: Quartz Commercial |
$5,029.70
|
| Rate for Payer: Quartz Medicare Advantage |
$4,642.80
|
| Rate for Payer: The Alliance Commercial |
$30,952.00
|
| Rate for Payer: WEA Trust Commercial |
$4,255.90
|
| Rate for Payer: WPS Commercial |
$5,731.54
|
|
|
2B1322 Sod. Chl. 250cc
|
Facility
OP
|
$48.00
|
|
| Hospital Charge Code |
3101786
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$41.28
|
| Rate for Payer: Aetna Managed Medicare |
$13.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.86
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$31.20
|
| Rate for Payer: Quartz Medicare Advantage |
$28.80
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
|
2B1322 Sod. Chl. 250cc
|
Facility
IP
|
$48.00
|
|
| Hospital Charge Code |
3101786
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$44.16 |
| Rate for Payer: Aetna Commercial |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.44
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$44.16
|
| Rate for Payer: Health EOS Commercial |
$42.72
|
| Rate for Payer: HFN Commercial |
$44.16
|
| Rate for Payer: Multiplan Commercial |
$38.40
|
| Rate for Payer: NAPHCARE Commercial |
$28.80
|
| Rate for Payer: Preferred Network Access Commercial |
$44.16
|
| Rate for Payer: Quartz Beloit One Network |
$23.52
|
| Rate for Payer: Quartz Commercial |
$28.80
|
| Rate for Payer: WEA Trust Commercial |
$26.40
|
| Rate for Payer: WPS Commercial |
$35.55
|
|
