|
6FR SHEATH-55CM
|
Facility
|
IP
|
$1,408.00
|
|
| Hospital Charge Code |
6175141
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$717.52 |
| Max. Negotiated Rate |
$1,347.17 |
| Rate for Payer: Aetna Commercial |
$1,317.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,259.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$776.09
|
| Rate for Payer: Cash Price |
$422.40
|
| Rate for Payer: Cigna Commercial |
$1,347.17
|
| Rate for Payer: Health EOS Commercial |
$1,303.24
|
| Rate for Payer: HFN Commercial |
$1,347.17
|
| Rate for Payer: Multiplan Commercial |
$1,171.46
|
| Rate for Payer: Preferred Network Access Commercial |
$1,347.17
|
| Rate for Payer: Quartz Beloit One Network |
$717.52
|
| Rate for Payer: Quartz Commercial |
$878.59
|
| Rate for Payer: WEA Trust Commercial |
$805.38
|
| Rate for Payer: WPS Commercial |
$1,084.58
|
|
|
6FR SHEATH-70CM
|
Facility
|
IP
|
$1,585.00
|
|
| Hospital Charge Code |
6175140
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$807.72 |
| Max. Negotiated Rate |
$1,516.53 |
| Rate for Payer: Aetna Commercial |
$1,483.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.65
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,516.53
|
| Rate for Payer: Health EOS Commercial |
$1,467.08
|
| Rate for Payer: HFN Commercial |
$1,516.53
|
| Rate for Payer: Multiplan Commercial |
$1,318.72
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.53
|
| Rate for Payer: Quartz Beloit One Network |
$807.72
|
| Rate for Payer: Quartz Commercial |
$989.04
|
| Rate for Payer: WEA Trust Commercial |
$906.62
|
| Rate for Payer: WPS Commercial |
$1,220.93
|
|
|
6FR SHEATH-70CM
|
Facility
|
OP
|
$1,585.00
|
|
| Hospital Charge Code |
6175140
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$461.55 |
| Max. Negotiated Rate |
$1,516.53 |
| Rate for Payer: Aetna Commercial |
$1,483.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,417.62
|
| Rate for Payer: Aetna Managed Medicare |
$461.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,071.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$824.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$791.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$873.65
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,516.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$922.47
|
| Rate for Payer: Health EOS Commercial |
$1,467.08
|
| Rate for Payer: HFN Commercial |
$1,516.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,236.30
|
| Rate for Payer: Multiplan Commercial |
$1,318.72
|
| Rate for Payer: NAPHCARE Commercial |
$989.04
|
| Rate for Payer: Preferred Network Access Commercial |
$1,516.53
|
| Rate for Payer: Quartz Beloit One Network |
$807.72
|
| Rate for Payer: Quartz Commercial |
$1,071.46
|
| Rate for Payer: Quartz Medicare Advantage |
$989.04
|
| Rate for Payer: The Alliance Commercial |
$824.20
|
| Rate for Payer: WEA Trust Commercial |
$906.62
|
| Rate for Payer: WPS Commercial |
$1,220.93
|
|
|
6Fr Super Flex
|
Facility
|
OP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$93.48 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Aetna Managed Medicare |
$93.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$166.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$186.82
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$250.38
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: NAPHCARE Commercial |
$200.30
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$217.00
|
| Rate for Payer: Quartz Medicare Advantage |
$200.30
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
6Fr Super Flex
|
Professional
|
Both
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.89 |
| Max. Negotiated Rate |
$317.15 |
| Rate for Payer: Aetna Commercial |
$317.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$317.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$166.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.30
|
| Rate for Payer: Health EOS Commercial |
$303.79
|
| Rate for Payer: HFN Commercial |
$317.15
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$317.15
|
| Rate for Payer: Quartz Beloit One Network |
$146.89
|
| Rate for Payer: Quartz Commercial |
$190.29
|
| Rate for Payer: The Alliance Commercial |
$166.92
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
6Fr Super Flex
|
Facility
|
IP
|
$321.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
2550894
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$163.58 |
| Max. Negotiated Rate |
$307.13 |
| Rate for Payer: Aetna Commercial |
$300.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$287.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$176.94
|
| Rate for Payer: Cash Price |
$96.30
|
| Rate for Payer: Cigna Commercial |
$307.13
|
| Rate for Payer: Health EOS Commercial |
$297.12
|
| Rate for Payer: HFN Commercial |
$307.13
|
| Rate for Payer: Multiplan Commercial |
$267.07
|
| Rate for Payer: Preferred Network Access Commercial |
$307.13
|
| Rate for Payer: Quartz Beloit One Network |
$163.58
|
| Rate for Payer: Quartz Commercial |
$200.30
|
| Rate for Payer: WEA Trust Commercial |
$183.61
|
| Rate for Payer: WPS Commercial |
$247.27
|
|
|
6-Monoacetylmorphine, Urine
|
Facility
|
IP
|
$202.00
|
|
|
Service Code
|
CPT 80356
|
| Hospital Charge Code |
4598988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.94 |
| Max. Negotiated Rate |
$193.27 |
| Rate for Payer: Aetna Commercial |
$189.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.34
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$193.27
|
| Rate for Payer: Health EOS Commercial |
$186.97
|
| Rate for Payer: HFN Commercial |
$193.27
|
| Rate for Payer: Multiplan Commercial |
$168.06
|
| Rate for Payer: Preferred Network Access Commercial |
$193.27
|
| Rate for Payer: Quartz Beloit One Network |
$102.94
|
| Rate for Payer: Quartz Commercial |
$126.05
|
| Rate for Payer: WEA Trust Commercial |
$115.54
|
| Rate for Payer: WPS Commercial |
$155.60
|
|
|
6-Monoacetylmorphine, Urine
|
Professional
|
Both
|
$202.00
|
|
|
Service Code
|
CPT 80356
|
| Hospital Charge Code |
4598988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$83.26 |
| Max. Negotiated Rate |
$199.58 |
| Rate for Payer: Aetna Commercial |
$199.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.67
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$199.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$105.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$126.05
|
| Rate for Payer: Health EOS Commercial |
$191.17
|
| Rate for Payer: HFN Commercial |
$199.58
|
| 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 |
$168.06
|
| Rate for Payer: Preferred Network Access Commercial |
$199.58
|
| Rate for Payer: Quartz Beloit One Network |
$92.44
|
| Rate for Payer: Quartz Commercial |
$119.75
|
| Rate for Payer: The Alliance Commercial |
$105.04
|
| Rate for Payer: WEA Trust Commercial |
$115.54
|
| Rate for Payer: WPS Commercial |
$155.60
|
|
|
6-Monoacetylmorphine, Urine
|
Facility
|
OP
|
$202.00
|
|
|
Service Code
|
CPT 80356
|
| Hospital Charge Code |
4598988
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.82 |
| Max. Negotiated Rate |
$193.27 |
| Rate for Payer: Aetna Commercial |
$189.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$180.67
|
| Rate for Payer: Aetna Managed Medicare |
$58.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$136.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$105.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$100.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$111.34
|
| Rate for Payer: Cash Price |
$60.60
|
| Rate for Payer: Cigna Commercial |
$193.27
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$117.56
|
| Rate for Payer: Health EOS Commercial |
$186.97
|
| Rate for Payer: HFN Commercial |
$193.27
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$157.56
|
| Rate for Payer: Multiplan Commercial |
$168.06
|
| Rate for Payer: NAPHCARE Commercial |
$126.05
|
| Rate for Payer: Preferred Network Access Commercial |
$193.27
|
| Rate for Payer: Quartz Beloit One Network |
$102.94
|
| Rate for Payer: Quartz Commercial |
$136.55
|
| Rate for Payer: Quartz Medicare Advantage |
$126.05
|
| Rate for Payer: The Alliance Commercial |
$105.04
|
| Rate for Payer: United Healthcare PPO |
$157.56
|
| Rate for Payer: WEA Trust Commercial |
$115.54
|
| Rate for Payer: WPS Commercial |
$155.60
|
|
|
7.5FR IAB-40cc
|
Facility
|
OP
|
$6,528.00
|
|
| Hospital Charge Code |
5184608
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,900.95 |
| Max. Negotiated Rate |
$6,245.99 |
| Rate for Payer: Aetna Commercial |
$6,110.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,838.64
|
| Rate for Payer: Aetna Managed Medicare |
$1,900.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,412.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,394.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,258.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,598.23
|
| Rate for Payer: Cash Price |
$1,958.40
|
| Rate for Payer: Cigna Commercial |
$6,245.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,799.30
|
| Rate for Payer: Health EOS Commercial |
$6,042.32
|
| Rate for Payer: HFN Commercial |
$6,245.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,091.84
|
| Rate for Payer: Multiplan Commercial |
$5,431.30
|
| Rate for Payer: NAPHCARE Commercial |
$4,073.47
|
| Rate for Payer: Preferred Network Access Commercial |
$6,245.99
|
| Rate for Payer: Quartz Beloit One Network |
$3,326.67
|
| Rate for Payer: Quartz Commercial |
$4,412.93
|
| Rate for Payer: Quartz Medicare Advantage |
$4,073.47
|
| Rate for Payer: The Alliance Commercial |
$3,394.56
|
| Rate for Payer: WEA Trust Commercial |
$3,734.02
|
| Rate for Payer: WPS Commercial |
$5,028.52
|
|
|
7.5FR IAB-40cc
|
Facility
|
IP
|
$6,528.00
|
|
| Hospital Charge Code |
5184608
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,326.67 |
| Max. Negotiated Rate |
$6,245.99 |
| Rate for Payer: Aetna Commercial |
$6,110.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,838.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,598.23
|
| Rate for Payer: Cash Price |
$1,958.40
|
| Rate for Payer: Cigna Commercial |
$6,245.99
|
| Rate for Payer: Health EOS Commercial |
$6,042.32
|
| Rate for Payer: HFN Commercial |
$6,245.99
|
| Rate for Payer: Multiplan Commercial |
$5,431.30
|
| Rate for Payer: Preferred Network Access Commercial |
$6,245.99
|
| Rate for Payer: Quartz Beloit One Network |
$3,326.67
|
| Rate for Payer: Quartz Commercial |
$4,073.47
|
| Rate for Payer: WEA Trust Commercial |
$3,734.02
|
| Rate for Payer: WPS Commercial |
$5,028.52
|
|
|
.76 DRILL BIT/MINI W/ 12MM STOP 316.292
|
Facility
|
IP
|
$2,187.00
|
|
| Hospital Charge Code |
2966170
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,114.50 |
| Max. Negotiated Rate |
$2,092.52 |
| Rate for Payer: Aetna Commercial |
$2,047.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,956.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,205.47
|
| Rate for Payer: Cash Price |
$656.10
|
| Rate for Payer: Cigna Commercial |
$2,092.52
|
| Rate for Payer: Health EOS Commercial |
$2,024.29
|
| Rate for Payer: HFN Commercial |
$2,092.52
|
| Rate for Payer: Multiplan Commercial |
$1,819.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,092.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,114.50
|
| Rate for Payer: Quartz Commercial |
$1,364.69
|
| Rate for Payer: WEA Trust Commercial |
$1,250.96
|
| Rate for Payer: WPS Commercial |
$1,684.65
|
|
|
.76 DRILL BIT/MINI W/ 12MM STOP 316.292
|
Facility
|
OP
|
$2,187.00
|
|
| Hospital Charge Code |
2966170
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.85 |
| Max. Negotiated Rate |
$2,092.52 |
| Rate for Payer: Aetna Commercial |
$2,047.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,956.05
|
| Rate for Payer: Aetna Managed Medicare |
$636.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,478.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,137.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,091.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,205.47
|
| Rate for Payer: Cash Price |
$656.10
|
| Rate for Payer: Cigna Commercial |
$2,092.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,272.83
|
| Rate for Payer: Health EOS Commercial |
$2,024.29
|
| Rate for Payer: HFN Commercial |
$2,092.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,705.86
|
| Rate for Payer: Multiplan Commercial |
$1,819.58
|
| Rate for Payer: NAPHCARE Commercial |
$1,364.69
|
| Rate for Payer: Preferred Network Access Commercial |
$2,092.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,114.50
|
| Rate for Payer: Quartz Commercial |
$1,478.41
|
| Rate for Payer: Quartz Medicare Advantage |
$1,364.69
|
| Rate for Payer: The Alliance Commercial |
$1,137.24
|
| Rate for Payer: WEA Trust Commercial |
$1,250.96
|
| Rate for Payer: WPS Commercial |
$1,684.65
|
|
|
7FR Superflex Sheath
|
Facility
|
IP
|
$532.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4528617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.11 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$331.97
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
7FR Superflex Sheath
|
Facility
|
OP
|
$532.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4528617
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$154.92 |
| Max. Negotiated Rate |
$509.02 |
| Rate for Payer: Aetna Commercial |
$497.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$475.82
|
| Rate for Payer: Aetna Managed Medicare |
$154.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$359.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$276.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$265.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.24
|
| Rate for Payer: Cash Price |
$159.60
|
| Rate for Payer: Cigna Commercial |
$509.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$309.62
|
| Rate for Payer: Health EOS Commercial |
$492.42
|
| Rate for Payer: HFN Commercial |
$509.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$414.96
|
| Rate for Payer: Multiplan Commercial |
$442.62
|
| Rate for Payer: NAPHCARE Commercial |
$331.97
|
| Rate for Payer: Preferred Network Access Commercial |
$509.02
|
| Rate for Payer: Quartz Beloit One Network |
$271.11
|
| Rate for Payer: Quartz Commercial |
$359.63
|
| Rate for Payer: Quartz Medicare Advantage |
$331.97
|
| Rate for Payer: The Alliance Commercial |
$276.64
|
| Rate for Payer: WEA Trust Commercial |
$304.30
|
| Rate for Payer: WPS Commercial |
$409.80
|
|
|
80 mg - Firmagon Charge
|
Facility
|
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$505.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$388.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$373.40
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.63
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$505.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$18.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: Wellcare Medicare |
$4.63
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
80 mg - Firmagon Charge
|
Professional
|
Both
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$739.02 |
| Rate for Payer: Aetna Commercial |
$739.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$739.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.53
|
| Rate for Payer: Health EOS Commercial |
$707.91
|
| Rate for Payer: HFN Commercial |
$739.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$739.02
|
| Rate for Payer: Quartz Beloit One Network |
$342.28
|
| Rate for Payer: Quartz Commercial |
$443.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$12.73
|
| Rate for Payer: United Healthcare Medicaid |
$4.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
80 mg - Firmagon Charge
|
Facility
|
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183043
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$381.18 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$466.75
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$576.18
|
|
|
85103 AP Bill Bone Marrow Needle Bx
|
Facility
|
IP
|
$98.00
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
1034022
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
85103 AP Bill Bone Marrow Needle Bx
|
Facility
|
OP
|
$98.00
|
|
|
Service Code
|
CPT 88305
|
| Hospital Charge Code |
1034022
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$219.36 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$54.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$208.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$97.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.47
|
| Rate for Payer: Anthem Medicare Advantage |
$54.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$54.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$54.84
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$54.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$54.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$54.84
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$54.84
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$54.84
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$82.26
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$54.84
|
| Rate for Payer: The Alliance Commercial |
$219.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$54.84
|
| Rate for Payer: United Healthcare PPO |
$76.44
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: Wellcare Medicare |
$54.84
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
85535 AP Bill Iron Stain Bone Marrow (Smears)
|
Facility
|
OP
|
$192.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
1034021
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$560.06 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$235.79
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$110.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$104.38
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.74
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$129.79
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$149.76
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
85535 AP Bill Iron Stain Bone Marrow (Smears)
|
Facility
|
IP
|
$192.00
|
|
|
Service Code
|
CPT 88313
|
| Hospital Charge Code |
1034021
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$97.84 |
| Max. Negotiated Rate |
$183.71 |
| Rate for Payer: Aetna Commercial |
$179.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.83
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna Commercial |
$183.71
|
| Rate for Payer: Health EOS Commercial |
$177.72
|
| Rate for Payer: HFN Commercial |
$183.71
|
| Rate for Payer: Multiplan Commercial |
$159.74
|
| Rate for Payer: Preferred Network Access Commercial |
$183.71
|
| Rate for Payer: Quartz Beloit One Network |
$97.84
|
| Rate for Payer: Quartz Commercial |
$119.81
|
| Rate for Payer: WEA Trust Commercial |
$109.82
|
| Rate for Payer: WPS Commercial |
$147.90
|
|
|
88104 AP Bill Non-Gyn Cytology
|
Facility
|
OP
|
$187.00
|
|
|
Service Code
|
CPT 88104
|
| Hospital Charge Code |
295380
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Aetna Managed Medicare |
$39.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.43
|
| Rate for Payer: Anthem Medicare Advantage |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.31
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.31
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.31
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: NAPHCARE Commercial |
$58.97
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$126.41
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$157.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.31
|
| Rate for Payer: United Healthcare PPO |
$145.86
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: Wellcare Medicare |
$39.31
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
88104 AP Bill Non-Gyn Cytology
|
Facility
|
IP
|
$187.00
|
|
|
Service Code
|
CPT 88104
|
| Hospital Charge Code |
295380
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$95.30 |
| Max. Negotiated Rate |
$178.92 |
| Rate for Payer: Aetna Commercial |
$175.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$167.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$103.07
|
| Rate for Payer: Cash Price |
$56.10
|
| Rate for Payer: Cigna Commercial |
$178.92
|
| Rate for Payer: Health EOS Commercial |
$173.09
|
| Rate for Payer: HFN Commercial |
$178.92
|
| Rate for Payer: Multiplan Commercial |
$155.58
|
| Rate for Payer: Preferred Network Access Commercial |
$178.92
|
| Rate for Payer: Quartz Beloit One Network |
$95.30
|
| Rate for Payer: Quartz Commercial |
$116.69
|
| Rate for Payer: WEA Trust Commercial |
$106.96
|
| Rate for Payer: WPS Commercial |
$144.05
|
|
|
88106 AP Bill Cyto Non-Gyn Filter Method
|
Facility
|
IP
|
$44.00
|
|
|
Service Code
|
CPT 88106
|
| Hospital Charge Code |
1034024
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$42.10 |
| Rate for Payer: Aetna Commercial |
$41.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$39.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$24.25
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$42.10
|
| Rate for Payer: Health EOS Commercial |
$40.73
|
| Rate for Payer: HFN Commercial |
$42.10
|
| Rate for Payer: Multiplan Commercial |
$36.61
|
| Rate for Payer: Preferred Network Access Commercial |
$42.10
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$27.46
|
| Rate for Payer: WEA Trust Commercial |
$25.17
|
| Rate for Payer: WPS Commercial |
$33.89
|
|
