|
21-Hydroxylase Antibody
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.98 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$128.54
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
21-Hydroxylase Antibody
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$192.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.49
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.77
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$113.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$197.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$119.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$190.67
|
| Rate for Payer: HFN Commercial |
$197.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$197.10
|
| Rate for Payer: Quartz Beloit One Network |
$104.98
|
| Rate for Payer: Quartz Commercial |
$139.26
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$76.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: United Healthcare PPO |
$160.68
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: Wellcare Medicare |
$19.14
|
| Rate for Payer: WPS Commercial |
$158.68
|
|
|
21-Hydroxylase Antibody
|
Professional
|
Both
|
$206.00
|
|
|
Service Code
|
CPT 83519
|
| Hospital Charge Code |
3959982
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$203.53 |
| Rate for Payer: Aetna Commercial |
$203.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$184.25
|
| Rate for Payer: Aetna Managed Medicare |
$19.14
|
| Rate for Payer: Anthem Medicare Advantage |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.14
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cash Price |
$61.80
|
| Rate for Payer: Cigna Commercial |
$203.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$107.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$194.96
|
| Rate for Payer: HFN Commercial |
$203.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$67.55
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$171.39
|
| Rate for Payer: NAPHCARE Commercial |
$28.70
|
| Rate for Payer: Preferred Network Access Commercial |
$203.53
|
| Rate for Payer: Quartz Beloit One Network |
$94.27
|
| Rate for Payer: Quartz Commercial |
$122.12
|
| Rate for Payer: Quartz Medicare Advantage |
$19.14
|
| Rate for Payer: The Alliance Commercial |
$75.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.14
|
| Rate for Payer: WEA Trust Commercial |
$117.83
|
| Rate for Payer: WPS Commercial |
$84.20
|
|
|
2:1 Nursing Daily - Devices and Equipment
|
Facility
|
OP
|
$2,073.00
|
|
| Hospital Charge Code |
3002387
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$603.66 |
| Max. Negotiated Rate |
$1,983.45 |
| Rate for Payer: Aetna Commercial |
$1,940.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,854.09
|
| Rate for Payer: Aetna Managed Medicare |
$603.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,401.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,077.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,034.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,142.64
|
| Rate for Payer: Cash Price |
$621.90
|
| Rate for Payer: Cigna Commercial |
$1,983.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,206.49
|
| Rate for Payer: Health EOS Commercial |
$1,918.77
|
| Rate for Payer: HFN Commercial |
$1,983.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,616.94
|
| Rate for Payer: Multiplan Commercial |
$1,724.74
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,983.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,056.40
|
| Rate for Payer: Quartz Commercial |
$1,401.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1,293.55
|
| Rate for Payer: The Alliance Commercial |
$1,077.96
|
| Rate for Payer: WEA Trust Commercial |
$1,185.76
|
| Rate for Payer: WPS Commercial |
$1,596.83
|
|
|
2:1 Nursing Daily - Devices and Equipment
|
Facility
|
IP
|
$2,073.00
|
|
| Hospital Charge Code |
3002387
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$1,056.40 |
| Max. Negotiated Rate |
$1,983.45 |
| Rate for Payer: Aetna Commercial |
$1,940.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,854.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,142.64
|
| Rate for Payer: Cash Price |
$621.90
|
| Rate for Payer: Cigna Commercial |
$1,983.45
|
| Rate for Payer: Health EOS Commercial |
$1,918.77
|
| Rate for Payer: HFN Commercial |
$1,983.45
|
| Rate for Payer: Multiplan Commercial |
$1,724.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,983.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,056.40
|
| Rate for Payer: Quartz Commercial |
$1,293.55
|
| Rate for Payer: WEA Trust Commercial |
$1,185.76
|
| Rate for Payer: WPS Commercial |
$1,596.83
|
|
|
22 - Catheter size
|
Facility
|
OP
|
$93.00
|
|
| Hospital Charge Code |
2999972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Aetna Managed Medicare |
$27.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.13
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: NAPHCARE Commercial |
$58.03
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$62.87
|
| Rate for Payer: Quartz Medicare Advantage |
$58.03
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
22 - Catheter size
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2999972
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
22 G 1*6231""
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
3040302
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
22 G 1*6231""
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
3040302
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Managed Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.33
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: NAPHCARE Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2.50
|
| Rate for Payer: The Alliance Commercial |
$2.08
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
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 |
$43.44 |
| Max. Negotiated Rate |
$646.80 |
| Rate for Payer: Aetna Commercial |
$632.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.61
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.11
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$646.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$43.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$393.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$625.71
|
| Rate for Payer: HFN Commercial |
$646.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$43.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$562.43
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$646.80
|
| Rate for Payer: Quartz Beloit One Network |
$344.49
|
| Rate for Payer: Quartz Commercial |
$456.98
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$173.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: United Healthcare PPO |
$527.28
|
| Rate for Payer: WEA Trust Commercial |
$386.67
|
| Rate for Payer: Wellcare Medicare |
$43.44
|
| Rate for Payer: WPS Commercial |
$520.72
|
|
|
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 |
$344.49 |
| Max. Negotiated Rate |
$646.80 |
| Rate for Payer: Aetna Commercial |
$632.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$372.61
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$646.80
|
| Rate for Payer: Health EOS Commercial |
$625.71
|
| Rate for Payer: HFN Commercial |
$646.80
|
| Rate for Payer: Multiplan Commercial |
$562.43
|
| Rate for Payer: Preferred Network Access Commercial |
$646.80
|
| Rate for Payer: Quartz Beloit One Network |
$344.49
|
| Rate for Payer: Quartz Commercial |
$421.82
|
| Rate for Payer: WEA Trust Commercial |
$386.67
|
| Rate for Payer: WPS Commercial |
$520.72
|
|
|
2,3-Dinor 11 Beta-Prostaglandin F2 Alpha, Urine
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5841647
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$667.89 |
| Rate for Payer: Aetna Commercial |
$667.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$604.61
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cash Price |
$202.80
|
| Rate for Payer: Cigna Commercial |
$667.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$351.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$639.77
|
| Rate for Payer: HFN Commercial |
$667.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$153.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$562.43
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$667.89
|
| Rate for Payer: Quartz Beloit One Network |
$309.34
|
| Rate for Payer: Quartz Commercial |
$400.73
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$171.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: WEA Trust Commercial |
$386.67
|
| Rate for Payer: WPS Commercial |
$191.14
|
|
|
240 mg - Firmagon Charge
|
Facility
|
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$505.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$388.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$373.40
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.63
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$505.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$18.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: Wellcare Medicare |
$4.63
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
240 mg - Firmagon Charge
|
Facility
|
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$381.18 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$466.75
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$576.18
|
|
|
240 mg - Firmagon Charge
|
Professional
|
Both
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$739.02 |
| Rate for Payer: Aetna Commercial |
$739.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$739.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.53
|
| Rate for Payer: Health EOS Commercial |
$707.91
|
| Rate for Payer: HFN Commercial |
$739.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$739.02
|
| Rate for Payer: Quartz Beloit One Network |
$342.28
|
| Rate for Payer: Quartz Commercial |
$443.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$12.73
|
| Rate for Payer: United Healthcare Medicaid |
$4.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
24 - Catheter size
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2999971
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
24 - Catheter size
|
Facility
|
OP
|
$93.00
|
|
| Hospital Charge Code |
2999971
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Aetna Managed Medicare |
$27.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.13
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: NAPHCARE Commercial |
$58.03
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$62.87
|
| Rate for Payer: Quartz Medicare Advantage |
$58.03
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
24 G 1.25
|
Facility
|
IP
|
$4.00
|
|
| Hospital Charge Code |
3040303
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.50
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
24 G 1.25
|
Facility
|
OP
|
$4.00
|
|
| Hospital Charge Code |
3040303
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3.58
|
| Rate for Payer: Aetna Managed Medicare |
$1.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.20
|
| Rate for Payer: Cash Price |
$1.20
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.33
|
| Rate for Payer: Health EOS Commercial |
$3.70
|
| Rate for Payer: HFN Commercial |
$3.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.12
|
| Rate for Payer: Multiplan Commercial |
$3.33
|
| Rate for Payer: NAPHCARE Commercial |
$2.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3.83
|
| Rate for Payer: Quartz Beloit One Network |
$2.04
|
| Rate for Payer: Quartz Commercial |
$2.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2.50
|
| Rate for Payer: The Alliance Commercial |
$2.08
|
| Rate for Payer: WEA Trust Commercial |
$2.29
|
| Rate for Payer: WPS Commercial |
$3.08
|
|
|
2.5 Hours - Respiratory Therapy Treatment Duration
|
Facility
|
IP
|
$1,289.00
|
|
| Hospital Charge Code |
3023873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$656.87 |
| Max. Negotiated Rate |
$1,233.32 |
| Rate for Payer: Aetna Commercial |
$1,206.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,152.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.50
|
| Rate for Payer: Cash Price |
$386.70
|
| Rate for Payer: Cigna Commercial |
$1,233.32
|
| Rate for Payer: Health EOS Commercial |
$1,193.10
|
| Rate for Payer: HFN Commercial |
$1,233.32
|
| Rate for Payer: Multiplan Commercial |
$1,072.45
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.32
|
| Rate for Payer: Quartz Beloit One Network |
$656.87
|
| Rate for Payer: Quartz Commercial |
$804.34
|
| Rate for Payer: WEA Trust Commercial |
$737.31
|
| Rate for Payer: WPS Commercial |
$992.92
|
|
|
2.5 Hours - Respiratory Therapy Treatment Duration
|
Facility
|
OP
|
$1,289.00
|
|
| Hospital Charge Code |
3023873
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$375.36 |
| Max. Negotiated Rate |
$1,233.32 |
| Rate for Payer: Aetna Commercial |
$1,206.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,152.88
|
| Rate for Payer: Aetna Managed Medicare |
$375.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$871.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$670.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$643.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.50
|
| Rate for Payer: Cash Price |
$386.70
|
| Rate for Payer: Cigna Commercial |
$1,233.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$750.20
|
| Rate for Payer: Health EOS Commercial |
$1,193.10
|
| Rate for Payer: HFN Commercial |
$1,233.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,005.42
|
| Rate for Payer: Multiplan Commercial |
$1,072.45
|
| Rate for Payer: NAPHCARE Commercial |
$804.34
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.32
|
| Rate for Payer: Quartz Beloit One Network |
$656.87
|
| Rate for Payer: Quartz Commercial |
$871.36
|
| Rate for Payer: Quartz Medicare Advantage |
$804.34
|
| Rate for Payer: The Alliance Commercial |
$670.28
|
| Rate for Payer: WEA Trust Commercial |
$737.31
|
| Rate for Payer: WPS Commercial |
$992.92
|
|
|
272 STERILE SUPPLY
|
Facility
|
IP
|
$7,738.00
|
|
| Hospital Charge Code |
3054515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,943.28 |
| Max. Negotiated Rate |
$7,403.72 |
| Rate for Payer: Aetna Commercial |
$7,242.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,920.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,265.19
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,403.72
|
| Rate for Payer: Health EOS Commercial |
$7,162.29
|
| Rate for Payer: HFN Commercial |
$7,403.72
|
| Rate for Payer: Multiplan Commercial |
$6,438.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,403.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,943.28
|
| Rate for Payer: Quartz Commercial |
$4,828.51
|
| Rate for Payer: WEA Trust Commercial |
$4,426.14
|
| Rate for Payer: WPS Commercial |
$5,960.58
|
|
|
272 STERILE SUPPLY
|
Facility
|
OP
|
$7,738.00
|
|
| Hospital Charge Code |
3054515
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,253.31 |
| Max. Negotiated Rate |
$7,403.72 |
| Rate for Payer: Aetna Commercial |
$7,242.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,920.87
|
| Rate for Payer: Aetna Managed Medicare |
$2,253.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,230.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,023.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,862.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,265.19
|
| Rate for Payer: Cash Price |
$2,321.40
|
| Rate for Payer: Cigna Commercial |
$7,403.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,503.52
|
| Rate for Payer: Health EOS Commercial |
$7,162.29
|
| Rate for Payer: HFN Commercial |
$7,403.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,035.64
|
| Rate for Payer: Multiplan Commercial |
$6,438.02
|
| Rate for Payer: NAPHCARE Commercial |
$4,828.51
|
| Rate for Payer: Preferred Network Access Commercial |
$7,403.72
|
| Rate for Payer: Quartz Beloit One Network |
$3,943.28
|
| Rate for Payer: Quartz Commercial |
$5,230.89
|
| Rate for Payer: Quartz Medicare Advantage |
$4,828.51
|
| Rate for Payer: The Alliance Commercial |
$4,023.76
|
| Rate for Payer: WEA Trust Commercial |
$4,426.14
|
| Rate for Payer: WPS Commercial |
$5,960.58
|
|
|
2B1322 Sod. Chl. 250cc
|
Facility
|
IP
|
$48.00
|
|
| Hospital Charge Code |
3101786
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$29.95
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
|
2B1322 Sod. Chl. 250cc
|
Facility
|
OP
|
$48.00
|
|
| Hospital Charge Code |
3101786
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$45.93 |
| Rate for Payer: Aetna Commercial |
$44.93
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.93
|
| Rate for Payer: Aetna Managed Medicare |
$13.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$26.46
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna Commercial |
$45.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.94
|
| Rate for Payer: Health EOS Commercial |
$44.43
|
| Rate for Payer: HFN Commercial |
$45.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$37.44
|
| Rate for Payer: Multiplan Commercial |
$39.94
|
| Rate for Payer: NAPHCARE Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$45.93
|
| Rate for Payer: Quartz Beloit One Network |
$24.46
|
| Rate for Payer: Quartz Commercial |
$32.45
|
| Rate for Payer: Quartz Medicare Advantage |
$29.95
|
| Rate for Payer: The Alliance Commercial |
$24.96
|
| Rate for Payer: WEA Trust Commercial |
$27.46
|
| Rate for Payer: WPS Commercial |
$36.97
|
|
