|
Promus 4.0mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162856
|
|
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 4.0mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162856
|
|
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 4.0mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162858
|
|
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 4.0mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162858
|
|
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 4.0mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162858
|
|
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 4.0mm x 8mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162848
|
|
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 4.0mm x 8mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162848
|
|
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 4.0mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162848
|
|
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
|
|
|
Proparacaine 0.5% Ophth Solution 15ml (refrigerator) [Med]
|
Facility
|
IP
|
$78.00
|
|
| Hospital Charge Code |
2974975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Proparacaine 0.5% Ophth Solution 15ml (refrigerator) [Med]
|
Facility
|
OP
|
$78.00
|
|
| Hospital Charge Code |
2974975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$312.00 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Aetna Managed Medicare |
$21.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.65
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.50
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$50.70
|
| Rate for Payer: Quartz Medicare Advantage |
$46.80
|
| Rate for Payer: The Alliance Commercial |
$312.00
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
|
Propofol JW Waste Charge per 10 mg
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
HCPCS J2704 JW
|
| Hospital Charge Code |
5266706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$128.00 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.16
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$20.80
|
| Rate for Payer: Quartz Medicare Advantage |
$19.20
|
| Rate for Payer: The Alliance Commercial |
$128.00
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$0.31
|
|
|
Propofol JW Waste Charge per 10 mg
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
HCPCS J2704 JW
|
| Hospital Charge Code |
5266706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna Commercial |
$28.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.96
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$29.44
|
| Rate for Payer: Health EOS Commercial |
$28.48
|
| Rate for Payer: HFN Commercial |
$29.44
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: NAPHCARE Commercial |
$19.20
|
| Rate for Payer: Preferred Network Access Commercial |
$29.44
|
| Rate for Payer: Quartz Beloit One Network |
$15.68
|
| Rate for Payer: Quartz Commercial |
$19.20
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$23.70
|
|
|
Propofol JW Waste Charge per 10 mg
|
Professional
|
Both
|
$32.00
|
|
|
Service Code
|
HCPCS J2704 JW
|
| Hospital Charge Code |
5266706
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$30.40 |
| Rate for Payer: Aetna Commercial |
$30.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$27.52
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.12
|
| Rate for Payer: Health EOS Commercial |
$29.12
|
| Rate for Payer: HFN Commercial |
$30.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$25.60
|
| Rate for Payer: Preferred Network Access Commercial |
$30.40
|
| Rate for Payer: Quartz Beloit One Network |
$14.08
|
| Rate for Payer: Quartz Commercial |
$18.24
|
| Rate for Payer: The Alliance Commercial |
$16.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.13
|
| Rate for Payer: WEA Trust Commercial |
$17.60
|
| Rate for Payer: WPS Commercial |
$0.31
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$66.44 |
| Max. Negotiated Rate |
$143.45 |
| Rate for Payer: Aetna Commercial |
$143.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$143.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$75.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$90.60
|
| Rate for Payer: Health EOS Commercial |
$137.41
|
| Rate for Payer: HFN Commercial |
$143.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: Preferred Network Access Commercial |
$143.45
|
| Rate for Payer: Quartz Beloit One Network |
$66.44
|
| Rate for Payer: Quartz Commercial |
$86.07
|
| Rate for Payer: The Alliance Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.99 |
| Max. Negotiated Rate |
$138.92 |
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$90.60
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.28 |
| Max. Negotiated Rate |
$604.00 |
| Rate for Payer: Aetna Commercial |
$135.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.86
|
| Rate for Payer: Aetna Managed Medicare |
$42.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$80.03
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$138.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.50
|
| Rate for Payer: Health EOS Commercial |
$134.39
|
| Rate for Payer: HFN Commercial |
$138.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.25
|
| Rate for Payer: Multiplan Commercial |
$120.80
|
| Rate for Payer: NAPHCARE Commercial |
$90.60
|
| Rate for Payer: Preferred Network Access Commercial |
$138.92
|
| Rate for Payer: Quartz Beloit One Network |
$73.99
|
| Rate for Payer: Quartz Commercial |
$98.15
|
| Rate for Payer: Quartz Medicare Advantage |
$90.60
|
| Rate for Payer: The Alliance Commercial |
$604.00
|
| Rate for Payer: United Healthcare PPO |
$113.25
|
| Rate for Payer: WEA Trust Commercial |
$83.05
|
| Rate for Payer: WPS Commercial |
$111.85
|
|
|
Propylene Glycol
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.11 |
| Max. Negotiated Rate |
$329.36 |
| Rate for Payer: Aetna Commercial |
$322.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Aetna Managed Medicare |
$17.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.16
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.94
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.40
|
| Rate for Payer: Anthem Medicaid |
$17.68
|
| Rate for Payer: Anthem Medicare Advantage |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.11
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$329.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.34
|
| Rate for Payer: Dean Health Medicaid |
$17.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.11
|
| Rate for Payer: Health EOS Commercial |
$318.62
|
| Rate for Payer: HFN Commercial |
$329.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.11
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.11
|
| Rate for Payer: Managed Health Services Medicaid |
$18.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.11
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: NAPHCARE Commercial |
$25.66
|
| Rate for Payer: Preferred Network Access Commercial |
$329.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.68
|
| Rate for Payer: Quartz Beloit One Network |
$175.42
|
| Rate for Payer: Quartz Commercial |
$232.70
|
| Rate for Payer: Quartz Medicare Advantage |
$17.11
|
| Rate for Payer: The Alliance Commercial |
$68.44
|
| Rate for Payer: United Healthcare Medicaid |
$17.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.11
|
| Rate for Payer: United Healthcare PPO |
$268.50
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: Wellcare Medicare |
$17.11
|
| Rate for Payer: WMAP Medicaid |
$17.68
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Propylene Glycol
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$175.42 |
| Max. Negotiated Rate |
$329.36 |
| Rate for Payer: Aetna Commercial |
$322.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$189.74
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$329.36
|
| Rate for Payer: Health EOS Commercial |
$318.62
|
| Rate for Payer: HFN Commercial |
$329.36
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: NAPHCARE Commercial |
$214.80
|
| Rate for Payer: Preferred Network Access Commercial |
$329.36
|
| Rate for Payer: Quartz Beloit One Network |
$175.42
|
| Rate for Payer: Quartz Commercial |
$214.80
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Propylene Glycol
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$60.40 |
| Max. Negotiated Rate |
$340.10 |
| Rate for Payer: Aetna Commercial |
$340.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$307.88
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$340.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$179.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$214.80
|
| Rate for Payer: Health EOS Commercial |
$325.78
|
| Rate for Payer: HFN Commercial |
$340.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.40
|
| Rate for Payer: Multiplan Commercial |
$286.40
|
| Rate for Payer: Preferred Network Access Commercial |
$340.10
|
| Rate for Payer: Quartz Beloit One Network |
$157.52
|
| Rate for Payer: Quartz Commercial |
$204.06
|
| Rate for Payer: The Alliance Commercial |
$179.00
|
| Rate for Payer: WEA Trust Commercial |
$196.90
|
| Rate for Payer: WPS Commercial |
$265.17
|
|
|
Prosource 1oz
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3031451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.80
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Prosource 1oz
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3031451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Prosource 32oz
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
3031452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.16 |
| Max. Negotiated Rate |
$688.00 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Aetna Managed Medicare |
$48.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$111.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$86.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$82.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.25
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$129.00
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$111.80
|
| Rate for Payer: Quartz Medicare Advantage |
$103.20
|
| Rate for Payer: The Alliance Commercial |
$688.00
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Prosource 32oz
|
Facility
|
IP
|
$172.00
|
|
| Hospital Charge Code |
3031452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$84.28 |
| Max. Negotiated Rate |
$158.24 |
| Rate for Payer: Aetna Commercial |
$154.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$147.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.16
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$158.24
|
| Rate for Payer: Health EOS Commercial |
$153.08
|
| Rate for Payer: HFN Commercial |
$158.24
|
| Rate for Payer: Multiplan Commercial |
$137.60
|
| Rate for Payer: NAPHCARE Commercial |
$103.20
|
| Rate for Payer: Preferred Network Access Commercial |
$158.24
|
| Rate for Payer: Quartz Beloit One Network |
$84.28
|
| Rate for Payer: Quartz Commercial |
$103.20
|
| Rate for Payer: WEA Trust Commercial |
$94.60
|
| Rate for Payer: WPS Commercial |
$127.40
|
|
|
Prostaglandin D2 (PGD2)
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$492.20 |
| Rate for Payer: Aetna Commercial |
$481.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Aetna Managed Medicare |
$41.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$156.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$73.10
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.34
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.77
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$492.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$41.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$299.39
|
| Rate for Payer: Dean Health Medicaid |
$35.09
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$41.77
|
| Rate for Payer: Health EOS Commercial |
$476.15
|
| Rate for Payer: HFN Commercial |
$492.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$155.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$41.77
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.77
|
| Rate for Payer: Managed Health Services Medicaid |
$36.49
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$41.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$41.77
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: NAPHCARE Commercial |
$62.66
|
| Rate for Payer: Preferred Network Access Commercial |
$492.20
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$35.09
|
| Rate for Payer: Quartz Beloit One Network |
$262.15
|
| Rate for Payer: Quartz Commercial |
$347.75
|
| Rate for Payer: Quartz Medicare Advantage |
$41.77
|
| Rate for Payer: The Alliance Commercial |
$167.08
|
| Rate for Payer: United Healthcare Medicaid |
$35.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.77
|
| Rate for Payer: United Healthcare PPO |
$401.25
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: Wellcare Medicare |
$41.77
|
| Rate for Payer: WMAP Medicaid |
$35.09
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
|
Prostaglandin D2 (PGD2)
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$262.15 |
| Max. Negotiated Rate |
$492.20 |
| Rate for Payer: Aetna Commercial |
$481.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$460.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.55
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$492.20
|
| Rate for Payer: Health EOS Commercial |
$476.15
|
| Rate for Payer: HFN Commercial |
$492.20
|
| Rate for Payer: Multiplan Commercial |
$428.00
|
| Rate for Payer: NAPHCARE Commercial |
$321.00
|
| Rate for Payer: Preferred Network Access Commercial |
$492.20
|
| Rate for Payer: Quartz Beloit One Network |
$262.15
|
| Rate for Payer: Quartz Commercial |
$321.00
|
| Rate for Payer: WEA Trust Commercial |
$294.25
|
| Rate for Payer: WPS Commercial |
$396.27
|
|
