|
PROLARYN GEL IMPLANT 1ML (SHORT TERM 3-6 M) 8602M0K5
|
Facility
|
OP
|
$4,823.00
|
|
|
Service Code
|
HCPCS L8607
|
| Hospital Charge Code |
5497079
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,350.44 |
| Max. Negotiated Rate |
$19,292.00 |
| Rate for Payer: Aetna Commercial |
$4,340.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,147.78
|
| Rate for Payer: Aetna Managed Medicare |
$1,350.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,134.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,411.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,315.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,556.19
|
| Rate for Payer: Cash Price |
$1,446.90
|
| Rate for Payer: Cigna Commercial |
$4,437.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,698.95
|
| Rate for Payer: Health EOS Commercial |
$4,292.47
|
| Rate for Payer: HFN Commercial |
$4,437.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,617.25
|
| Rate for Payer: Multiplan Commercial |
$3,858.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,893.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,437.16
|
| Rate for Payer: Quartz Beloit One Network |
$2,363.27
|
| Rate for Payer: Quartz Commercial |
$3,134.95
|
| Rate for Payer: Quartz Medicare Advantage |
$2,893.80
|
| Rate for Payer: The Alliance Commercial |
$19,292.00
|
| Rate for Payer: WEA Trust Commercial |
$2,652.65
|
| Rate for Payer: WPS Commercial |
$3,572.40
|
|
|
PROLARYN PLUS INJECTABLE IMPLANT 1ML (LONG TERM 1-2YR) 5033877
|
Facility
|
IP
|
$4,433.00
|
|
|
Service Code
|
HCPCS L8607
|
| Hospital Charge Code |
5184695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,172.17 |
| Max. Negotiated Rate |
$4,078.36 |
| Rate for Payer: Aetna Commercial |
$3,989.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,812.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,349.49
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,078.36
|
| Rate for Payer: Health EOS Commercial |
$3,945.37
|
| Rate for Payer: HFN Commercial |
$4,078.36
|
| Rate for Payer: Multiplan Commercial |
$3,546.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,659.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,078.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,172.17
|
| Rate for Payer: Quartz Commercial |
$2,659.80
|
| Rate for Payer: WEA Trust Commercial |
$2,438.15
|
| Rate for Payer: WPS Commercial |
$3,283.52
|
|
|
PROLARYN PLUS INJECTABLE IMPLANT 1ML (LONG TERM 1-2YR) 5033877
|
Facility
|
OP
|
$4,433.00
|
|
|
Service Code
|
HCPCS L8607
|
| Hospital Charge Code |
5184695
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,241.24 |
| Max. Negotiated Rate |
$17,732.00 |
| Rate for Payer: Aetna Commercial |
$3,989.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,812.38
|
| Rate for Payer: Aetna Managed Medicare |
$1,241.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,881.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,216.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,127.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,349.49
|
| Rate for Payer: Cash Price |
$1,329.90
|
| Rate for Payer: Cigna Commercial |
$4,078.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,480.71
|
| Rate for Payer: Health EOS Commercial |
$3,945.37
|
| Rate for Payer: HFN Commercial |
$4,078.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,324.75
|
| Rate for Payer: Multiplan Commercial |
$3,546.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,659.80
|
| Rate for Payer: Preferred Network Access Commercial |
$4,078.36
|
| Rate for Payer: Quartz Beloit One Network |
$2,172.17
|
| Rate for Payer: Quartz Commercial |
$2,881.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,659.80
|
| Rate for Payer: The Alliance Commercial |
$17,732.00
|
| Rate for Payer: WEA Trust Commercial |
$2,438.15
|
| Rate for Payer: WPS Commercial |
$3,283.52
|
|
|
Prolia/XGEVA 1 mg Charge
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
2958986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$62.97 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.19
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: HFN Commercial |
$51.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$29.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.33
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: United Healthcare Medicaid |
$25.19
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$62.97
|
|
|
Prolia/XGEVA 1 mg Charge
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
2958986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.19 |
| Max. Negotiated Rate |
$100.79 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.19
|
| Rate for Payer: Anthem Medicare Advantage |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.20
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.74
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.20
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| Rate for Payer: Quartz Medicare Advantage |
$25.20
|
| Rate for Payer: The Alliance Commercial |
$100.79
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.20
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$25.20
|
| Rate for Payer: WPS Commercial |
$62.97
|
|
|
Prolia/XGEVA 1 mg Charge
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
2958986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
PROLONGED CARE IN ADDITION TO At-Home Care G0318
|
Professional
|
Both
|
$77.00
|
|
|
Service Code
|
HCPCS G0318
|
| Hospital Charge Code |
6196534
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$23.25 |
| Max. Negotiated Rate |
$73.15 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.20
|
| Rate for Payer: Health EOS Commercial |
$70.07
|
| Rate for Payer: HFN Commercial |
$73.15
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: Preferred Network Access Commercial |
$73.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.88
|
| Rate for Payer: Quartz Commercial |
$43.89
|
| Rate for Payer: The Alliance Commercial |
$38.50
|
| Rate for Payer: United Healthcare Medicaid |
$23.25
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Prolonged Evaluation and Management Service, First Hour
|
Professional
|
Both
|
$384.00
|
|
|
Service Code
|
CPT 99358
|
| Hospital Charge Code |
1122819
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$168.96 |
| Max. Negotiated Rate |
$374.36 |
| Rate for Payer: Aetna Commercial |
$364.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$330.24
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cash Price |
$115.20
|
| Rate for Payer: Cigna Commercial |
$364.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$230.40
|
| Rate for Payer: Health EOS Commercial |
$349.44
|
| Rate for Payer: HFN Commercial |
$364.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$374.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$374.36
|
| Rate for Payer: Multiplan Commercial |
$307.20
|
| Rate for Payer: Preferred Network Access Commercial |
$364.80
|
| Rate for Payer: Quartz Beloit One Network |
$168.96
|
| Rate for Payer: Quartz Commercial |
$218.88
|
| Rate for Payer: The Alliance Commercial |
$192.00
|
| Rate for Payer: WEA Trust Commercial |
$211.20
|
| Rate for Payer: WPS Commercial |
$284.43
|
|
|
PROLONGED SERV, W/O CONTACT 99359
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
CPT 99359
|
| Hospital Charge Code |
3015558
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$84.48 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$182.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.12
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$182.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$96.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$115.20
|
| Rate for Payer: Health EOS Commercial |
$174.72
|
| Rate for Payer: HFN Commercial |
$182.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$179.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.89
|
| Rate for Payer: Multiplan Commercial |
$153.60
|
| Rate for Payer: Preferred Network Access Commercial |
$182.40
|
| Rate for Payer: Quartz Beloit One Network |
$84.48
|
| Rate for Payer: Quartz Commercial |
$109.44
|
| Rate for Payer: The Alliance Commercial |
$96.00
|
| Rate for Payer: WEA Trust Commercial |
$105.60
|
| Rate for Payer: WPS Commercial |
$142.21
|
|
|
Prolong Outpt/Office each add 15min 99417
|
Professional
|
Both
|
$77.00
|
|
|
Service Code
|
CPT 99417
|
| Hospital Charge Code |
5673635
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$33.88 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.20
|
| Rate for Payer: Health EOS Commercial |
$70.07
|
| Rate for Payer: HFN Commercial |
$73.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.30
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: Preferred Network Access Commercial |
$73.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.88
|
| Rate for Payer: Quartz Commercial |
$43.89
|
| Rate for Payer: The Alliance Commercial |
$38.50
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Prolong Outpt/Office Vis Mdcre E add 15min G2212
|
Professional
|
Both
|
$77.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
5683627
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.99 |
| Max. Negotiated Rate |
$108.30 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$66.22
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.20
|
| Rate for Payer: Health EOS Commercial |
$70.07
|
| Rate for Payer: HFN Commercial |
$73.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.30
|
| Rate for Payer: Multiplan Commercial |
$61.60
|
| Rate for Payer: Preferred Network Access Commercial |
$73.15
|
| Rate for Payer: Quartz Beloit One Network |
$33.88
|
| Rate for Payer: Quartz Commercial |
$43.89
|
| Rate for Payer: The Alliance Commercial |
$38.50
|
| Rate for Payer: United Healthcare Medicaid |
$24.99
|
| Rate for Payer: WEA Trust Commercial |
$42.35
|
| Rate for Payer: WPS Commercial |
$57.03
|
|
|
Promethazine hcl inj 50 MG J2550
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Promethazine hcl inj 50 MG J2550
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.10
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$7.75
|
|
|
Promethazine hcl inj 50 MG J2550
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
3407525
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$7.75 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.10
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.46
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3.46
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: United Healthcare Medicaid |
$3.10
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$7.75
|
|
|
Promote Rth 1000 mL
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
3031449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.01 |
| Max. Negotiated Rate |
$45.08 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$29.40
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Promote Rth 1000 mL
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
3031449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: Aetna Commercial |
$44.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$42.14
|
| Rate for Payer: Aetna Managed Medicare |
$13.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$25.97
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$45.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27.42
|
| Rate for Payer: Health EOS Commercial |
$43.61
|
| Rate for Payer: HFN Commercial |
$45.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$36.75
|
| Rate for Payer: Multiplan Commercial |
$39.20
|
| Rate for Payer: NAPHCARE Commercial |
$29.40
|
| Rate for Payer: Preferred Network Access Commercial |
$45.08
|
| Rate for Payer: Quartz Beloit One Network |
$24.01
|
| Rate for Payer: Quartz Commercial |
$31.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.40
|
| Rate for Payer: The Alliance Commercial |
$196.00
|
| Rate for Payer: WEA Trust Commercial |
$26.95
|
| Rate for Payer: WPS Commercial |
$36.29
|
|
|
Promote w/Fiber Rth 1000 mL
|
Facility
|
OP
|
$66.00
|
|
| Hospital Charge Code |
3031450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.48 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Aetna Managed Medicare |
$18.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.93
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.50
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$39.60
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$42.90
|
| Rate for Payer: Quartz Medicare Advantage |
$39.60
|
| Rate for Payer: The Alliance Commercial |
$264.00
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Promote w/Fiber Rth 1000 mL
|
Facility
|
IP
|
$66.00
|
|
| Hospital Charge Code |
3031450
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.34 |
| Max. Negotiated Rate |
$60.72 |
| Rate for Payer: Aetna Commercial |
$59.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.98
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$60.72
|
| Rate for Payer: Health EOS Commercial |
$58.74
|
| Rate for Payer: HFN Commercial |
$60.72
|
| Rate for Payer: Multiplan Commercial |
$52.80
|
| Rate for Payer: NAPHCARE Commercial |
$39.60
|
| Rate for Payer: Preferred Network Access Commercial |
$60.72
|
| Rate for Payer: Quartz Beloit One Network |
$32.34
|
| Rate for Payer: Quartz Commercial |
$39.60
|
| Rate for Payer: WEA Trust Commercial |
$36.30
|
| Rate for Payer: WPS Commercial |
$48.89
|
|
|
Promus 2.25mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162802
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162804
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Promus 2.25mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162806
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
