|
OLYMPUS 3MM ROLLER BALL 24FR M0068802641
|
Facility
|
OP
|
$1,134.00
|
|
| Hospital Charge Code |
4520042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.22 |
| Max. Negotiated Rate |
$1,085.01 |
| Rate for Payer: Aetna Commercial |
$1,061.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,014.25
|
| Rate for Payer: Aetna Managed Medicare |
$330.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$766.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$589.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.06
|
| Rate for Payer: Cash Price |
$340.20
|
| Rate for Payer: Cigna Commercial |
$1,085.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$659.99
|
| Rate for Payer: Health EOS Commercial |
$1,049.63
|
| Rate for Payer: HFN Commercial |
$1,085.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$884.52
|
| Rate for Payer: Multiplan Commercial |
$943.49
|
| Rate for Payer: NAPHCARE Commercial |
$707.62
|
| Rate for Payer: Preferred Network Access Commercial |
$1,085.01
|
| Rate for Payer: Quartz Beloit One Network |
$577.89
|
| Rate for Payer: Quartz Commercial |
$766.58
|
| Rate for Payer: Quartz Medicare Advantage |
$707.62
|
| Rate for Payer: The Alliance Commercial |
$589.68
|
| Rate for Payer: WEA Trust Commercial |
$648.65
|
| Rate for Payer: WPS Commercial |
$873.52
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
OP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.45 |
| Max. Negotiated Rate |
$2,328.85 |
| Rate for Payer: Aetna Commercial |
$2,278.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Aetna Managed Medicare |
$48.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,645.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,265.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,215.05
|
| Rate for Payer: Anthem Medicare Advantage |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,341.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.45
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,328.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$48.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$48.45
|
| Rate for Payer: Health EOS Commercial |
$2,252.91
|
| Rate for Payer: HFN Commercial |
$2,328.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$48.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$48.45
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: NAPHCARE Commercial |
$72.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,328.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,240.37
|
| Rate for Payer: Quartz Commercial |
$1,645.38
|
| Rate for Payer: Quartz Medicare Advantage |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$193.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.45
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: Wellcare Medicare |
$48.45
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab Charge 150 mg/5ml
|
Facility
|
IP
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,240.37 |
| Max. Negotiated Rate |
$2,328.85 |
| Rate for Payer: Aetna Commercial |
$2,278.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,341.62
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,328.85
|
| Rate for Payer: Health EOS Commercial |
$2,252.91
|
| Rate for Payer: HFN Commercial |
$2,328.85
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: Preferred Network Access Commercial |
$2,328.85
|
| Rate for Payer: Quartz Beloit One Network |
$1,240.37
|
| Rate for Payer: Quartz Commercial |
$1,518.82
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: WPS Commercial |
$1,874.91
|
|
|
Omalizumab Charge 150 mg/5ml
|
Professional
|
Both
|
$2,434.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
4506658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.28 |
| Max. Negotiated Rate |
$2,404.79 |
| Rate for Payer: Aetna Commercial |
$2,404.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,176.97
|
| Rate for Payer: Aetna Managed Medicare |
$48.45
|
| Rate for Payer: Anthem Medicare Advantage |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.45
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cash Price |
$730.20
|
| Rate for Payer: Cigna Commercial |
$2,404.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.28
|
| Rate for Payer: Health EOS Commercial |
$2,303.54
|
| Rate for Payer: HFN Commercial |
$2,404.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.45
|
| Rate for Payer: Multiplan Commercial |
$2,025.09
|
| Rate for Payer: NAPHCARE Commercial |
$72.68
|
| Rate for Payer: Preferred Network Access Commercial |
$2,404.79
|
| Rate for Payer: Quartz Beloit One Network |
$1,113.80
|
| Rate for Payer: Quartz Commercial |
$1,442.88
|
| Rate for Payer: Quartz Medicare Advantage |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$133.25
|
| Rate for Payer: United Healthcare Medicaid |
$47.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.45
|
| Rate for Payer: WEA Trust Commercial |
$1,392.25
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.44 |
| Max. Negotiated Rate |
$193.81 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$48.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.44
|
| Rate for Payer: Anthem Medicare Advantage |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.45
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$48.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$48.45
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$180.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$48.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$48.45
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$72.68
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$193.81
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.45
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: Wellcare Medicare |
$48.45
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
Omalizumab injection 5 Mg J2357
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
Omalizumab injection 5 Mg J2357
|
Professional
|
Both
|
$81.00
|
|
|
Service Code
|
HCPCS J2357
|
| Hospital Charge Code |
3382876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.07 |
| Max. Negotiated Rate |
$133.25 |
| Rate for Payer: Aetna Commercial |
$80.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$48.45
|
| Rate for Payer: Anthem Medicare Advantage |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$48.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$48.45
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$80.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$47.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.28
|
| Rate for Payer: Health EOS Commercial |
$76.66
|
| Rate for Payer: HFN Commercial |
$80.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$56.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$56.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$48.45
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$72.68
|
| Rate for Payer: Preferred Network Access Commercial |
$80.03
|
| Rate for Payer: Quartz Beloit One Network |
$37.07
|
| Rate for Payer: Quartz Commercial |
$48.02
|
| Rate for Payer: Quartz Medicare Advantage |
$48.45
|
| Rate for Payer: The Alliance Commercial |
$133.25
|
| Rate for Payer: United Healthcare Medicaid |
$47.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$48.45
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$95.70
|
|
|
OmegaCheck
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
OmegaCheck
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$107.64
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
OmegaCheck
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5867633
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$136.34 |
| Rate for Payer: Aetna Commercial |
$136.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$136.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$130.60
|
| Rate for Payer: HFN Commercial |
$136.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$136.34
|
| Rate for Payer: Quartz Beloit One Network |
$63.15
|
| Rate for Payer: Quartz Commercial |
$81.81
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
Omnipaque 100cc
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
Omnipaque 100cc
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 100cc
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
Omnipaque 100cc
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550876
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$240.08 |
| Rate for Payer: Aetna Commercial |
$240.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$0.17
|
| Rate for Payer: Anthem Medicare Advantage |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.17
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$240.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$229.98
|
| Rate for Payer: HFN Commercial |
$240.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$0.25
|
| Rate for Payer: Preferred Network Access Commercial |
$240.08
|
| Rate for Payer: Quartz Beloit One Network |
$111.20
|
| Rate for Payer: Quartz Commercial |
$144.05
|
| Rate for Payer: Quartz Medicare Advantage |
$0.17
|
| Rate for Payer: The Alliance Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.17
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 100cc
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$69.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$160.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.64
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$148.51
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$148.51
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 150cc
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$182.44 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$223.39
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Omnipaque 150cc
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444865
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Aetna Managed Medicare |
$104.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$186.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$178.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$279.24
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: NAPHCARE Commercial |
$223.39
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$242.01
|
| Rate for Payer: Quartz Medicare Advantage |
$223.39
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 150cc
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$348.28 |
| Rate for Payer: Aetna Commercial |
$340.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Aetna Managed Medicare |
$106.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$246.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$189.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$181.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.64
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$348.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$348.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$283.92
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: NAPHCARE Commercial |
$227.14
|
| Rate for Payer: Preferred Network Access Commercial |
$348.28
|
| Rate for Payer: Quartz Beloit One Network |
$185.49
|
| Rate for Payer: Quartz Commercial |
$246.06
|
| Rate for Payer: Quartz Medicare Advantage |
$227.14
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 150cc
|
Professional
|
Both
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$359.63 |
| Rate for Payer: Aetna Commercial |
$359.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Aetna Managed Medicare |
$0.17
|
| Rate for Payer: Anthem Medicare Advantage |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.17
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$359.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$344.49
|
| Rate for Payer: HFN Commercial |
$359.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: NAPHCARE Commercial |
$0.25
|
| Rate for Payer: Preferred Network Access Commercial |
$359.63
|
| Rate for Payer: Quartz Beloit One Network |
$166.57
|
| Rate for Payer: Quartz Commercial |
$215.78
|
| Rate for Payer: Quartz Medicare Advantage |
$0.17
|
| Rate for Payer: The Alliance Commercial |
$0.46
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.17
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 150cc
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550874
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$185.49 |
| Max. Negotiated Rate |
$348.28 |
| Rate for Payer: Aetna Commercial |
$340.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$325.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$200.64
|
| Rate for Payer: Cash Price |
$109.20
|
| Rate for Payer: Cigna Commercial |
$348.28
|
| Rate for Payer: Health EOS Commercial |
$336.92
|
| Rate for Payer: HFN Commercial |
$348.28
|
| Rate for Payer: Multiplan Commercial |
$302.85
|
| Rate for Payer: Preferred Network Access Commercial |
$348.28
|
| Rate for Payer: Quartz Beloit One Network |
$185.49
|
| Rate for Payer: Quartz Commercial |
$227.14
|
| Rate for Payer: WEA Trust Commercial |
$208.21
|
| Rate for Payer: WPS Commercial |
$280.39
|
|
|
OMNIPAQUE 180 10ml VIAL [MED]
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
6165976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.06 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$101.71
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$125.56
|
|
|
OMNIPAQUE 180 10ml VIAL [MED]
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
6165976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$155.96 |
| Rate for Payer: Aetna Commercial |
$152.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$145.79
|
| Rate for Payer: Aetna Managed Medicare |
$47.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$110.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$84.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$81.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$89.85
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cash Price |
$48.90
|
| Rate for Payer: Cigna Commercial |
$155.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$150.87
|
| Rate for Payer: HFN Commercial |
$155.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$127.14
|
| Rate for Payer: Multiplan Commercial |
$135.62
|
| Rate for Payer: NAPHCARE Commercial |
$101.71
|
| Rate for Payer: Preferred Network Access Commercial |
$155.96
|
| Rate for Payer: Quartz Beloit One Network |
$83.06
|
| Rate for Payer: Quartz Commercial |
$110.19
|
| Rate for Payer: Quartz Medicare Advantage |
$101.71
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$93.24
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
OMNIPAQUE 240 20ml VIAL [MED]
|
Facility
|
IP
|
$43.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
6165975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.91 |
| Max. Negotiated Rate |
$41.14 |
| Rate for Payer: Aetna Commercial |
$40.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.70
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Cigna Commercial |
$41.14
|
| Rate for Payer: Health EOS Commercial |
$39.80
|
| Rate for Payer: HFN Commercial |
$41.14
|
| Rate for Payer: Multiplan Commercial |
$35.78
|
| Rate for Payer: Preferred Network Access Commercial |
$41.14
|
| Rate for Payer: Quartz Beloit One Network |
$21.91
|
| Rate for Payer: Quartz Commercial |
$26.83
|
| Rate for Payer: WEA Trust Commercial |
$24.60
|
| Rate for Payer: WPS Commercial |
$33.12
|
|
|
OMNIPAQUE 240 20ml VIAL [MED]
|
Facility
|
OP
|
$43.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
6165975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$41.14 |
| Rate for Payer: Aetna Commercial |
$40.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$38.46
|
| Rate for Payer: Aetna Managed Medicare |
$12.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$22.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$21.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$23.70
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Cash Price |
$12.90
|
| Rate for Payer: Cigna Commercial |
$41.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$39.80
|
| Rate for Payer: HFN Commercial |
$41.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.54
|
| Rate for Payer: Multiplan Commercial |
$35.78
|
| Rate for Payer: NAPHCARE Commercial |
$26.83
|
| Rate for Payer: Preferred Network Access Commercial |
$41.14
|
| Rate for Payer: Quartz Beloit One Network |
$21.91
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: Quartz Medicare Advantage |
$26.83
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$24.60
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 240 50ml
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
1158850
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
