|
Omnipaque 350 50 ml
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.64 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$74.26
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$91.67
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.82
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$74.26
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$80.44
|
| Rate for Payer: Quartz Medicare Advantage |
$74.26
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$0.67
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$119.55 |
| Rate for Payer: Aetna Commercial |
$119.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| 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 |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| 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 |
$114.51
|
| Rate for Payer: HFN Commercial |
$119.55
|
| 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 |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$0.25
|
| Rate for Payer: Preferred Network Access Commercial |
$119.55
|
| Rate for Payer: Quartz Beloit One Network |
$55.37
|
| Rate for Payer: Quartz Commercial |
$71.73
|
| 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 |
$69.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omniscan 10ml
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$160.99
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
Omniscan 10ml
|
Professional
|
Both
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$118.06 |
| Max. Negotiated Rate |
$254.90 |
| Rate for Payer: Aetna Commercial |
$254.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$254.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$134.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.99
|
| Rate for Payer: Health EOS Commercial |
$244.17
|
| Rate for Payer: HFN Commercial |
$254.90
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$254.90
|
| Rate for Payer: Quartz Beloit One Network |
$118.06
|
| Rate for Payer: Quartz Commercial |
$152.94
|
| Rate for Payer: The Alliance Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
Omniscan 10ml
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.13 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$75.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.16
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.24
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$160.99
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$174.41
|
| Rate for Payer: Quartz Medicare Advantage |
$160.99
|
| Rate for Payer: The Alliance Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
Omniscan 15ml
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.55 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$230.88
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Omniscan 15ml
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.74 |
| Max. Negotiated Rate |
$354.02 |
| Rate for Payer: Aetna Commercial |
$346.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Aetna Managed Medicare |
$107.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$250.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$192.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$184.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$203.94
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$354.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$215.34
|
| Rate for Payer: Health EOS Commercial |
$342.47
|
| Rate for Payer: HFN Commercial |
$354.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.60
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: NAPHCARE Commercial |
$230.88
|
| Rate for Payer: Preferred Network Access Commercial |
$354.02
|
| Rate for Payer: Quartz Beloit One Network |
$188.55
|
| Rate for Payer: Quartz Commercial |
$250.12
|
| Rate for Payer: Quartz Medicare Advantage |
$230.88
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Omniscan 15ml
|
Professional
|
Both
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$169.31 |
| Max. Negotiated Rate |
$365.56 |
| Rate for Payer: Aetna Commercial |
$365.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.93
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$365.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.88
|
| Rate for Payer: Health EOS Commercial |
$350.17
|
| Rate for Payer: HFN Commercial |
$365.56
|
| Rate for Payer: Multiplan Commercial |
$307.84
|
| Rate for Payer: Preferred Network Access Commercial |
$365.56
|
| Rate for Payer: Quartz Beloit One Network |
$169.31
|
| Rate for Payer: Quartz Commercial |
$219.34
|
| Rate for Payer: The Alliance Commercial |
$192.40
|
| Rate for Payer: WEA Trust Commercial |
$211.64
|
| Rate for Payer: WPS Commercial |
$285.01
|
|
|
Omniscan 20 ml
|
Facility
|
OP
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.36 |
| Max. Negotiated Rate |
$461.18 |
| Rate for Payer: Aetna Commercial |
$451.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$431.10
|
| Rate for Payer: Aetna Managed Medicare |
$140.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$325.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$250.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$240.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.68
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$461.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$280.52
|
| Rate for Payer: Health EOS Commercial |
$446.14
|
| Rate for Payer: HFN Commercial |
$461.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$375.96
|
| Rate for Payer: Multiplan Commercial |
$401.02
|
| Rate for Payer: NAPHCARE Commercial |
$300.77
|
| Rate for Payer: Preferred Network Access Commercial |
$461.18
|
| Rate for Payer: Quartz Beloit One Network |
$245.63
|
| Rate for Payer: Quartz Commercial |
$325.83
|
| Rate for Payer: Quartz Medicare Advantage |
$300.77
|
| Rate for Payer: The Alliance Commercial |
$250.64
|
| Rate for Payer: WEA Trust Commercial |
$275.70
|
| Rate for Payer: WPS Commercial |
$371.28
|
|
|
Omniscan 20 ml
|
Facility
|
IP
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$245.63 |
| Max. Negotiated Rate |
$461.18 |
| Rate for Payer: Aetna Commercial |
$451.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$431.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$265.68
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$461.18
|
| Rate for Payer: Health EOS Commercial |
$446.14
|
| Rate for Payer: HFN Commercial |
$461.18
|
| Rate for Payer: Multiplan Commercial |
$401.02
|
| Rate for Payer: Preferred Network Access Commercial |
$461.18
|
| Rate for Payer: Quartz Beloit One Network |
$245.63
|
| Rate for Payer: Quartz Commercial |
$300.77
|
| Rate for Payer: WEA Trust Commercial |
$275.70
|
| Rate for Payer: WPS Commercial |
$371.28
|
|
|
Omniscan 20 ml
|
Professional
|
Both
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$220.56 |
| Max. Negotiated Rate |
$476.22 |
| Rate for Payer: Aetna Commercial |
$476.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$431.10
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$476.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$250.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$300.77
|
| Rate for Payer: Health EOS Commercial |
$456.16
|
| Rate for Payer: HFN Commercial |
$476.22
|
| Rate for Payer: Multiplan Commercial |
$401.02
|
| Rate for Payer: Preferred Network Access Commercial |
$476.22
|
| Rate for Payer: Quartz Beloit One Network |
$220.56
|
| Rate for Payer: Quartz Commercial |
$285.73
|
| Rate for Payer: The Alliance Commercial |
$250.64
|
| Rate for Payer: WEA Trust Commercial |
$275.70
|
| Rate for Payer: WPS Commercial |
$371.28
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
IP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,816.74 |
| Max. Negotiated Rate |
$9,043.67 |
| Rate for Payer: Aetna Commercial |
$8,847.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,453.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,209.94
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$9,043.67
|
| Rate for Payer: Health EOS Commercial |
$8,748.77
|
| Rate for Payer: HFN Commercial |
$9,043.67
|
| Rate for Payer: Multiplan Commercial |
$7,864.06
|
| Rate for Payer: Preferred Network Access Commercial |
$9,043.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,816.74
|
| Rate for Payer: Quartz Commercial |
$5,898.05
|
| Rate for Payer: WEA Trust Commercial |
$5,406.54
|
| Rate for Payer: WPS Commercial |
$7,280.88
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
OP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,752.42 |
| Max. Negotiated Rate |
$9,043.67 |
| Rate for Payer: Aetna Commercial |
$8,847.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,453.87
|
| Rate for Payer: Aetna Managed Medicare |
$2,752.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,389.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,915.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,718.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,209.94
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$9,043.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,501.06
|
| Rate for Payer: Health EOS Commercial |
$8,748.77
|
| Rate for Payer: HFN Commercial |
$9,043.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,372.56
|
| Rate for Payer: Multiplan Commercial |
$7,864.06
|
| Rate for Payer: NAPHCARE Commercial |
$5,898.05
|
| Rate for Payer: Preferred Network Access Commercial |
$9,043.67
|
| Rate for Payer: Quartz Beloit One Network |
$4,816.74
|
| Rate for Payer: Quartz Commercial |
$6,389.55
|
| Rate for Payer: Quartz Medicare Advantage |
$5,898.05
|
| Rate for Payer: The Alliance Commercial |
$4,915.04
|
| Rate for Payer: WEA Trust Commercial |
$5,406.54
|
| Rate for Payer: WPS Commercial |
$7,280.88
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
IP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$807.72 |
| Max. Negotiated Rate |
$1,516.53 |
| Rate for Payer: Aetna Commercial |
$1,483.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.65
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,516.53
|
| Rate for Payer: Health EOS Commercial |
$1,467.08
|
| Rate for Payer: HFN Commercial |
$1,516.53
|
| Rate for Payer: Multiplan Commercial |
$1,318.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.53
|
| Rate for Payer: Quartz Beloit One Network |
$807.72
|
| Rate for Payer: Quartz Commercial |
$989.04
|
| Rate for Payer: WEA Trust Commercial |
$906.62
|
| Rate for Payer: WPS Commercial |
$1,220.93
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
OP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$1,516.53 |
| Rate for Payer: Aetna Commercial |
$1,483.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.62
|
| Rate for Payer: Aetna Managed Medicare |
$6.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,071.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$824.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$791.23
|
| Rate for Payer: Anthem Medicare Advantage |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.77
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,516.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.77
|
| Rate for Payer: Health EOS Commercial |
$1,467.08
|
| Rate for Payer: HFN Commercial |
$1,516.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.77
|
| Rate for Payer: Multiplan Commercial |
$1,318.72
|
| Rate for Payer: NAPHCARE Commercial |
$10.16
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.53
|
| Rate for Payer: Quartz Beloit One Network |
$807.72
|
| Rate for Payer: Quartz Commercial |
$1,071.46
|
| Rate for Payer: Quartz Medicare Advantage |
$6.77
|
| Rate for Payer: The Alliance Commercial |
$27.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.77
|
| Rate for Payer: WEA Trust Commercial |
$906.62
|
| Rate for Payer: Wellcare Medicare |
$6.77
|
| Rate for Payer: WPS Commercial |
$16.43
|
|
|
Oncovin 1 mg Charge
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$56.45 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Aetna Managed Medicare |
$17.18
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$39.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.89
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.02
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: NAPHCARE Commercial |
$36.82
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$39.88
|
| Rate for Payer: Quartz Medicare Advantage |
$36.82
|
| Rate for Payer: The Alliance Commercial |
$39.64
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$20.58
|
|
|
Oncovin 1 mg Charge
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.07 |
| Max. Negotiated Rate |
$56.45 |
| Rate for Payer: Aetna Commercial |
$55.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.45
|
| Rate for Payer: Health EOS Commercial |
$54.61
|
| Rate for Payer: HFN Commercial |
$56.45
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: Preferred Network Access Commercial |
$56.45
|
| Rate for Payer: Quartz Beloit One Network |
$30.07
|
| Rate for Payer: Quartz Commercial |
$36.82
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$45.45
|
|
|
Oncovin 1 mg Charge
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.58 |
| Max. Negotiated Rate |
$58.29 |
| Rate for Payer: Aetna Commercial |
$58.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$52.77
|
| Rate for Payer: Aetna Managed Medicare |
$9.91
|
| Rate for Payer: Anthem Medicare Advantage |
$9.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.91
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$58.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.23
|
| Rate for Payer: Health EOS Commercial |
$55.84
|
| Rate for Payer: HFN Commercial |
$58.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.91
|
| Rate for Payer: Multiplan Commercial |
$49.09
|
| Rate for Payer: NAPHCARE Commercial |
$14.87
|
| Rate for Payer: Preferred Network Access Commercial |
$58.29
|
| Rate for Payer: Quartz Beloit One Network |
$27.00
|
| Rate for Payer: Quartz Commercial |
$34.98
|
| Rate for Payer: Quartz Medicare Advantage |
$9.91
|
| Rate for Payer: The Alliance Commercial |
$27.26
|
| Rate for Payer: United Healthcare Medicaid |
$8.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.91
|
| Rate for Payer: WEA Trust Commercial |
$33.75
|
| Rate for Payer: WPS Commercial |
$20.58
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.25
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$1.54
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna Commercial |
$1.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.09
|
| Rate for Payer: Anthem Medicare Advantage |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.09
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$1.89
|
| Rate for Payer: HFN Commercial |
$1.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$0.14
|
| Rate for Payer: Preferred Network Access Commercial |
$1.98
|
| Rate for Payer: Quartz Beloit One Network |
$0.92
|
| Rate for Payer: Quartz Commercial |
$1.19
|
| Rate for Payer: Quartz Medicare Advantage |
$0.09
|
| Rate for Payer: The Alliance Commercial |
$0.26
|
| Rate for Payer: United Healthcare Medicaid |
$0.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.09
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$0.25
|
|
|
Ondansetrion hcl inj 1 mg J2405
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J2405
|
| Hospital Charge Code |
3935359
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$1.91 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.79
|
| Rate for Payer: Aetna Managed Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.10
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$1.85
|
| Rate for Payer: HFN Commercial |
$1.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.56
|
| Rate for Payer: Multiplan Commercial |
$1.66
|
| Rate for Payer: NAPHCARE Commercial |
$1.25
|
| Rate for Payer: Preferred Network Access Commercial |
$1.91
|
| Rate for Payer: Quartz Beloit One Network |
$1.02
|
| Rate for Payer: Quartz Commercial |
$1.35
|
| Rate for Payer: Quartz Medicare Advantage |
$1.25
|
| Rate for Payer: The Alliance Commercial |
$0.37
|
| Rate for Payer: WEA Trust Commercial |
$1.14
|
| Rate for Payer: WPS Commercial |
$0.25
|
|
