|
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 |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Proparacaine 0.5% Ophth Solution 15ml (refrigerator) [Med]
|
Facility
|
OP
|
$78.00
|
|
| Hospital Charge Code |
2974975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.71 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Aetna Managed Medicare |
$22.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.40
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.84
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: NAPHCARE Commercial |
$48.67
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$52.73
|
| Rate for Payer: Quartz Medicare Advantage |
$48.67
|
| Rate for Payer: The Alliance Commercial |
$40.56
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
Proparacaine 0.5% Ophth Solution 15ml (refrigerator) [Med]
|
Facility
|
IP
|
$78.00
|
|
| Hospital Charge Code |
2974975
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.75 |
| Max. Negotiated Rate |
$74.63 |
| Rate for Payer: Aetna Commercial |
$73.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$69.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.99
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$74.63
|
| Rate for Payer: Health EOS Commercial |
$72.20
|
| Rate for Payer: HFN Commercial |
$74.63
|
| Rate for Payer: Multiplan Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$74.63
|
| Rate for Payer: Quartz Beloit One Network |
$39.75
|
| Rate for Payer: Quartz Commercial |
$48.67
|
| Rate for Payer: WEA Trust Commercial |
$44.62
|
| Rate for Payer: WPS Commercial |
$60.08
|
|
|
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 |
$16.31 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$19.97
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$24.65
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$30.62 |
| Rate for Payer: Aetna Commercial |
$29.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Aetna Managed Medicare |
$9.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$17.64
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$30.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.17
|
| Rate for Payer: Health EOS Commercial |
$29.62
|
| Rate for Payer: HFN Commercial |
$30.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.96
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: NAPHCARE Commercial |
$19.97
|
| Rate for Payer: Preferred Network Access Commercial |
$30.62
|
| Rate for Payer: Quartz Beloit One Network |
$16.31
|
| Rate for Payer: Quartz Commercial |
$21.63
|
| Rate for Payer: Quartz Medicare Advantage |
$19.97
|
| Rate for Payer: The Alliance Commercial |
$16.64
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$0.32
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$31.62 |
| Rate for Payer: Aetna Commercial |
$31.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$28.62
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$31.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.13
|
| Rate for Payer: Health EOS Commercial |
$30.28
|
| Rate for Payer: HFN Commercial |
$31.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$26.62
|
| Rate for Payer: Preferred Network Access Commercial |
$31.62
|
| Rate for Payer: Quartz Beloit One Network |
$14.64
|
| Rate for Payer: Quartz Commercial |
$18.97
|
| Rate for Payer: The Alliance Commercial |
$16.64
|
| Rate for Payer: United Healthcare Medicaid |
$0.09
|
| Rate for Payer: WEA Trust Commercial |
$18.30
|
| Rate for Payer: WPS Commercial |
$0.32
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Facility
|
IP
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.95 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$94.22
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Professional
|
Both
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.10 |
| Max. Negotiated Rate |
$149.19 |
| Rate for Payer: Aetna Commercial |
$149.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$149.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$78.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$94.22
|
| Rate for Payer: Health EOS Commercial |
$142.91
|
| Rate for Payer: HFN Commercial |
$149.19
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$83.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$83.26
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: Preferred Network Access Commercial |
$149.19
|
| Rate for Payer: Quartz Beloit One Network |
$69.10
|
| Rate for Payer: Quartz Commercial |
$89.51
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Propoxyphene, Quant, GC/MS, Urine
|
Facility
|
OP
|
$151.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
983369
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.97 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Aetna Commercial |
$141.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$135.05
|
| Rate for Payer: Aetna Managed Medicare |
$43.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$102.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$78.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$75.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$83.23
|
| Rate for Payer: Cash Price |
$45.30
|
| Rate for Payer: Cigna Commercial |
$144.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.88
|
| Rate for Payer: Health EOS Commercial |
$139.77
|
| Rate for Payer: HFN Commercial |
$144.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$117.78
|
| Rate for Payer: Multiplan Commercial |
$125.63
|
| Rate for Payer: NAPHCARE Commercial |
$94.22
|
| Rate for Payer: Preferred Network Access Commercial |
$144.48
|
| Rate for Payer: Quartz Beloit One Network |
$76.95
|
| Rate for Payer: Quartz Commercial |
$102.08
|
| Rate for Payer: Quartz Medicare Advantage |
$94.22
|
| Rate for Payer: The Alliance Commercial |
$78.52
|
| Rate for Payer: United Healthcare PPO |
$117.78
|
| Rate for Payer: WEA Trust Commercial |
$86.37
|
| Rate for Payer: WPS Commercial |
$116.32
|
|
|
Propylene Glycol
|
Professional
|
Both
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$353.70 |
| Rate for Payer: Aetna Commercial |
$353.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Aetna Managed Medicare |
$17.79
|
| Rate for Payer: Anthem Medicare Advantage |
$17.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.79
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$353.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$186.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.79
|
| Rate for Payer: Health EOS Commercial |
$338.81
|
| Rate for Payer: HFN Commercial |
$353.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.82
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.79
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: NAPHCARE Commercial |
$26.69
|
| Rate for Payer: Preferred Network Access Commercial |
$353.70
|
| Rate for Payer: Quartz Beloit One Network |
$163.82
|
| Rate for Payer: Quartz Commercial |
$212.22
|
| Rate for Payer: Quartz Medicare Advantage |
$17.79
|
| Rate for Payer: The Alliance Commercial |
$70.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.79
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$78.30
|
|
|
Propylene Glycol
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$182.44 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$223.39
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Propylene Glycol
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 84600
|
| Hospital Charge Code |
983370
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$342.53 |
| Rate for Payer: Aetna Commercial |
$335.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$320.20
|
| Rate for Payer: Aetna Managed Medicare |
$17.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.54
|
| Rate for Payer: Anthem Medicare Advantage |
$17.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.79
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cash Price |
$107.40
|
| Rate for Payer: Cigna Commercial |
$342.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.79
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$208.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.79
|
| Rate for Payer: Health EOS Commercial |
$331.36
|
| Rate for Payer: HFN Commercial |
$342.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.79
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.79
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.79
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.79
|
| Rate for Payer: Multiplan Commercial |
$297.86
|
| Rate for Payer: NAPHCARE Commercial |
$26.69
|
| Rate for Payer: Preferred Network Access Commercial |
$342.53
|
| Rate for Payer: Quartz Beloit One Network |
$182.44
|
| Rate for Payer: Quartz Commercial |
$242.01
|
| Rate for Payer: Quartz Medicare Advantage |
$17.79
|
| Rate for Payer: The Alliance Commercial |
$71.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.79
|
| Rate for Payer: United Healthcare PPO |
$279.24
|
| Rate for Payer: WEA Trust Commercial |
$204.78
|
| Rate for Payer: Wellcare Medicare |
$17.79
|
| Rate for Payer: WPS Commercial |
$275.77
|
|
|
Prosource 1oz
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
3031451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Prosource 1oz
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
3031451
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.91
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$2.60
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
Prosource 32oz
|
Facility
|
OP
|
$172.00
|
|
| Hospital Charge Code |
3031452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.09 |
| Max. Negotiated Rate |
$164.57 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Aetna Managed Medicare |
$50.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$116.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$89.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.10
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$134.16
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: NAPHCARE Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$116.27
|
| Rate for Payer: Quartz Medicare Advantage |
$107.33
|
| Rate for Payer: The Alliance Commercial |
$89.44
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
Prosource 32oz
|
Facility
|
IP
|
$172.00
|
|
| Hospital Charge Code |
3031452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$87.65 |
| Max. Negotiated Rate |
$164.57 |
| Rate for Payer: Aetna Commercial |
$160.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$153.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$94.81
|
| Rate for Payer: Cash Price |
$51.60
|
| Rate for Payer: Cigna Commercial |
$164.57
|
| Rate for Payer: Health EOS Commercial |
$159.20
|
| Rate for Payer: HFN Commercial |
$164.57
|
| Rate for Payer: Multiplan Commercial |
$143.10
|
| Rate for Payer: Preferred Network Access Commercial |
$164.57
|
| Rate for Payer: Quartz Beloit One Network |
$87.65
|
| Rate for Payer: Quartz Commercial |
$107.33
|
| Rate for Payer: WEA Trust Commercial |
$98.38
|
| Rate for Payer: WPS Commercial |
$132.49
|
|
|
Prostaglandin D2 (PGD2)
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.11
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$43.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$311.37
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$43.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$361.66
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$173.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: United Healthcare PPO |
$417.30
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: Wellcare Medicare |
$43.44
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
Prostaglandin D2 (PGD2)
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$528.58 |
| Rate for Payer: Aetna Commercial |
$528.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$528.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$278.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$506.32
|
| Rate for Payer: HFN Commercial |
$528.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$153.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$528.58
|
| Rate for Payer: Quartz Beloit One Network |
$244.82
|
| Rate for Payer: Quartz Commercial |
$317.15
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$171.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$191.14
|
|
|
Prostaglandin D2 (PGD2)
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$272.64 |
| Max. Negotiated Rate |
$511.89 |
| Rate for Payer: Aetna Commercial |
$500.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$478.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.89
|
| Rate for Payer: Cash Price |
$160.50
|
| Rate for Payer: Cigna Commercial |
$511.89
|
| Rate for Payer: Health EOS Commercial |
$495.20
|
| Rate for Payer: HFN Commercial |
$511.89
|
| Rate for Payer: Multiplan Commercial |
$445.12
|
| Rate for Payer: Preferred Network Access Commercial |
$511.89
|
| Rate for Payer: Quartz Beloit One Network |
$272.64
|
| Rate for Payer: Quartz Commercial |
$333.84
|
| Rate for Payer: WEA Trust Commercial |
$306.02
|
| Rate for Payer: WPS Commercial |
$412.11
|
|
|
Prostaglandin D2, Urine
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098632
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$571.06 |
| Rate for Payer: Aetna Commercial |
$571.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.96
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$571.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$300.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$547.02
|
| Rate for Payer: HFN Commercial |
$571.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$153.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$480.90
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$571.06
|
| Rate for Payer: Quartz Beloit One Network |
$264.49
|
| Rate for Payer: Quartz Commercial |
$342.64
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$171.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: WEA Trust Commercial |
$330.62
|
| Rate for Payer: WPS Commercial |
$191.14
|
|
|
Prostaglandin D2, Urine
|
Facility
|
IP
|
$578.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098632
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$294.55 |
| Max. Negotiated Rate |
$553.03 |
| Rate for Payer: Aetna Commercial |
$541.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.59
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$553.03
|
| Rate for Payer: Health EOS Commercial |
$535.00
|
| Rate for Payer: HFN Commercial |
$553.03
|
| Rate for Payer: Multiplan Commercial |
$480.90
|
| Rate for Payer: Preferred Network Access Commercial |
$553.03
|
| Rate for Payer: Quartz Beloit One Network |
$294.55
|
| Rate for Payer: Quartz Commercial |
$360.67
|
| Rate for Payer: WEA Trust Commercial |
$330.62
|
| Rate for Payer: WPS Commercial |
$445.23
|
|
|
Prostaglandin D2, Urine
|
Facility
|
OP
|
$578.00
|
|
|
Service Code
|
CPT 84150
|
| Hospital Charge Code |
5098632
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$43.44 |
| Max. Negotiated Rate |
$553.03 |
| Rate for Payer: Aetna Commercial |
$541.01
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.96
|
| Rate for Payer: Aetna Managed Medicare |
$43.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$162.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.02
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.11
|
| Rate for Payer: Anthem Medicare Advantage |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$318.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.44
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$553.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$43.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$43.44
|
| Rate for Payer: Health EOS Commercial |
$535.00
|
| Rate for Payer: HFN Commercial |
$553.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$161.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$43.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$43.44
|
| Rate for Payer: Multiplan Commercial |
$480.90
|
| Rate for Payer: NAPHCARE Commercial |
$65.16
|
| Rate for Payer: Preferred Network Access Commercial |
$553.03
|
| Rate for Payer: Quartz Beloit One Network |
$294.55
|
| Rate for Payer: Quartz Commercial |
$390.73
|
| Rate for Payer: Quartz Medicare Advantage |
$43.44
|
| Rate for Payer: The Alliance Commercial |
$173.76
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.44
|
| Rate for Payer: United Healthcare PPO |
$450.84
|
| Rate for Payer: WEA Trust Commercial |
$330.62
|
| Rate for Payer: Wellcare Medicare |
$43.44
|
| Rate for Payer: WPS Commercial |
$445.23
|
|
|
PROSTATECTOMY, OPEN
|
Facility
|
IP
|
$8,521.00
|
|
| Hospital Charge Code |
2960323
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,342.30 |
| Max. Negotiated Rate |
$8,152.89 |
| Rate for Payer: Aetna Commercial |
$7,975.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,621.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,696.78
|
| Rate for Payer: Cash Price |
$2,556.30
|
| Rate for Payer: Cigna Commercial |
$8,152.89
|
| Rate for Payer: Health EOS Commercial |
$7,887.04
|
| Rate for Payer: HFN Commercial |
$8,152.89
|
| Rate for Payer: Multiplan Commercial |
$7,089.47
|
| Rate for Payer: Preferred Network Access Commercial |
$8,152.89
|
| Rate for Payer: Quartz Beloit One Network |
$4,342.30
|
| Rate for Payer: Quartz Commercial |
$5,317.10
|
| Rate for Payer: WEA Trust Commercial |
$4,874.01
|
| Rate for Payer: WPS Commercial |
$6,563.73
|
|
