|
TONSIL BLEED
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2960437
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TONSIL BLEED
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2960437
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
TONSILLECTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960540
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TONSILLECTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960540
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TONSILLECTOMY/ADENOIDECTOMY
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960402
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$315.66 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Aetna Managed Medicare |
$315.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$732.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$563.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$541.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$630.89
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$845.52
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: NAPHCARE Commercial |
$676.42
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$732.78
|
| Rate for Payer: Quartz Medicare Advantage |
$676.42
|
| Rate for Payer: The Alliance Commercial |
$563.68
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TONSILLECTOMY/ADENOIDECTOMY
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960402
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$552.41 |
| Max. Negotiated Rate |
$1,037.17 |
| Rate for Payer: Aetna Commercial |
$1,014.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$969.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$597.50
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$1,037.17
|
| Rate for Payer: Health EOS Commercial |
$1,003.35
|
| Rate for Payer: HFN Commercial |
$1,037.17
|
| Rate for Payer: Multiplan Commercial |
$901.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,037.17
|
| Rate for Payer: Quartz Beloit One Network |
$552.41
|
| Rate for Payer: Quartz Commercial |
$676.42
|
| Rate for Payer: WEA Trust Commercial |
$620.05
|
| Rate for Payer: WPS Commercial |
$835.01
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$13,956.63
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$13,956.63 |
| Rate for Payer: Aetna Managed Medicare |
$3,489.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$3,489.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,489.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,489.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,489.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,489.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,979.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,489.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,489.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,489.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,489.16
|
| Rate for Payer: NAPHCARE Commercial |
$5,233.74
|
| Rate for Payer: Quartz Medicare Advantage |
$3,489.16
|
| Rate for Payer: The Alliance Commercial |
$13,956.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,489.16
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$3,489.16
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$24,919.86
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$24,919.86 |
| Rate for Payer: Aetna Managed Medicare |
$6,229.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,229.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,229.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,673.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,229.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,175.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,229.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,229.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,229.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,229.96
|
| Rate for Payer: NAPHCARE Commercial |
$9,344.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,229.96
|
| Rate for Payer: The Alliance Commercial |
$24,919.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,229.96
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$6,229.96
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$13,956.63
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,835.04 |
| Max. Negotiated Rate |
$13,956.63 |
| Rate for Payer: Aetna Managed Medicare |
$3,489.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$3,489.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,489.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,489.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,489.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,107.14
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,489.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,979.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,489.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,489.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,489.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,489.16
|
| Rate for Payer: NAPHCARE Commercial |
$5,233.74
|
| Rate for Payer: Quartz Medicare Advantage |
$3,489.16
|
| Rate for Payer: The Alliance Commercial |
$13,956.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,489.16
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$3,489.16
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$24,919.86
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,409.60 |
| Max. Negotiated Rate |
$24,919.86 |
| Rate for Payer: Aetna Managed Medicare |
$6,229.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,727.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,350.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,781.68
|
| Rate for Payer: Anthem Medicare Advantage |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,229.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,229.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,229.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,807.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,229.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23,175.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,229.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,229.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,229.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,229.96
|
| Rate for Payer: NAPHCARE Commercial |
$9,344.95
|
| Rate for Payer: Quartz Medicare Advantage |
$6,229.96
|
| Rate for Payer: The Alliance Commercial |
$24,919.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,229.96
|
| Rate for Payer: United Healthcare PPO |
$4,409.60
|
| Rate for Payer: Wellcare Medicare |
$6,229.96
|
|
|
TOPAZ EZ IFS ACH4041-01
|
Facility
|
IP
|
$4,399.00
|
|
| Hospital Charge Code |
5611610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,241.73 |
| Max. Negotiated Rate |
$4,208.96 |
| Rate for Payer: Aetna Commercial |
$4,117.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,934.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,424.73
|
| Rate for Payer: Cash Price |
$1,319.70
|
| Rate for Payer: Cigna Commercial |
$4,208.96
|
| Rate for Payer: Health EOS Commercial |
$4,071.71
|
| Rate for Payer: HFN Commercial |
$4,208.96
|
| Rate for Payer: Multiplan Commercial |
$3,659.97
|
| Rate for Payer: Preferred Network Access Commercial |
$4,208.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,241.73
|
| Rate for Payer: Quartz Commercial |
$2,744.98
|
| Rate for Payer: WEA Trust Commercial |
$2,516.23
|
| Rate for Payer: WPS Commercial |
$3,388.55
|
|
|
TOPAZ EZ IFS ACH4041-01
|
Facility
|
OP
|
$4,399.00
|
|
| Hospital Charge Code |
5611610
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,280.99 |
| Max. Negotiated Rate |
$4,208.96 |
| Rate for Payer: Aetna Commercial |
$4,117.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,934.47
|
| Rate for Payer: Aetna Managed Medicare |
$1,280.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,973.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,287.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,195.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,424.73
|
| Rate for Payer: Cash Price |
$1,319.70
|
| Rate for Payer: Cigna Commercial |
$4,208.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,560.22
|
| Rate for Payer: Health EOS Commercial |
$4,071.71
|
| Rate for Payer: HFN Commercial |
$4,208.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,431.22
|
| Rate for Payer: Multiplan Commercial |
$3,659.97
|
| Rate for Payer: NAPHCARE Commercial |
$2,744.98
|
| Rate for Payer: Preferred Network Access Commercial |
$4,208.96
|
| Rate for Payer: Quartz Beloit One Network |
$2,241.73
|
| Rate for Payer: Quartz Commercial |
$2,973.72
|
| Rate for Payer: Quartz Medicare Advantage |
$2,744.98
|
| Rate for Payer: The Alliance Commercial |
$2,287.48
|
| Rate for Payer: WEA Trust Commercial |
$2,516.23
|
| Rate for Payer: WPS Commercial |
$3,388.55
|
|
|
Topiramate Level
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$173.26 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Topiramate Level
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$335.92 |
| Rate for Payer: Aetna Commercial |
$335.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.40
|
| Rate for Payer: Anthem Medicare Advantage |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.40
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$335.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$176.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.40
|
| Rate for Payer: Health EOS Commercial |
$321.78
|
| Rate for Payer: HFN Commercial |
$335.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$43.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.40
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$335.92
|
| Rate for Payer: Quartz Beloit One Network |
$155.58
|
| Rate for Payer: Quartz Commercial |
$201.55
|
| Rate for Payer: Quartz Medicare Advantage |
$12.40
|
| Rate for Payer: The Alliance Commercial |
$48.97
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.40
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: WPS Commercial |
$54.55
|
|
|
Topiramate Level
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
978080
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.40 |
| Max. Negotiated Rate |
$325.31 |
| Rate for Payer: Aetna Commercial |
$318.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$304.10
|
| Rate for Payer: Aetna Managed Medicare |
$12.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.49
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.58
|
| Rate for Payer: Anthem Medicare Advantage |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$187.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.40
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cash Price |
$102.00
|
| Rate for Payer: Cigna Commercial |
$325.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$197.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.40
|
| Rate for Payer: Health EOS Commercial |
$314.70
|
| Rate for Payer: HFN Commercial |
$325.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.40
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.40
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.40
|
| Rate for Payer: Multiplan Commercial |
$282.88
|
| Rate for Payer: NAPHCARE Commercial |
$18.60
|
| Rate for Payer: Preferred Network Access Commercial |
$325.31
|
| Rate for Payer: Quartz Beloit One Network |
$173.26
|
| Rate for Payer: Quartz Commercial |
$229.84
|
| Rate for Payer: Quartz Medicare Advantage |
$12.40
|
| Rate for Payer: The Alliance Commercial |
$49.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.40
|
| Rate for Payer: United Healthcare PPO |
$265.20
|
| Rate for Payer: WEA Trust Commercial |
$194.48
|
| Rate for Payer: Wellcare Medicare |
$12.40
|
| Rate for Payer: WPS Commercial |
$261.90
|
|
|
Toposar 10 mg Charge
|
Facility
|
OP
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Aetna Managed Medicare |
$7.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.33
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.44
|
| Rate for Payer: Health EOS Commercial |
$24.07
|
| Rate for Payer: HFN Commercial |
$24.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.28
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: NAPHCARE Commercial |
$16.22
|
| Rate for Payer: Preferred Network Access Commercial |
$24.88
|
| Rate for Payer: Quartz Beloit One Network |
$13.25
|
| Rate for Payer: Quartz Commercial |
$17.58
|
| Rate for Payer: Quartz Medicare Advantage |
$16.22
|
| Rate for Payer: The Alliance Commercial |
$4.33
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$2.72
|
|
|
Toposar 10 mg Charge
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$25.69 |
| Rate for Payer: Aetna Commercial |
$25.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Aetna Managed Medicare |
$1.08
|
| Rate for Payer: Anthem Medicare Advantage |
$1.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1.08
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$25.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.09
|
| Rate for Payer: Health EOS Commercial |
$24.61
|
| Rate for Payer: HFN Commercial |
$25.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.09
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: NAPHCARE Commercial |
$1.62
|
| Rate for Payer: Preferred Network Access Commercial |
$25.69
|
| Rate for Payer: Quartz Beloit One Network |
$11.90
|
| Rate for Payer: Quartz Commercial |
$15.41
|
| Rate for Payer: Quartz Medicare Advantage |
$1.08
|
| Rate for Payer: The Alliance Commercial |
$2.97
|
| Rate for Payer: United Healthcare Medicaid |
$1.08
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1.08
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$2.72
|
|
|
Toposar 10 mg Charge
|
Facility
|
IP
|
$26.00
|
|
|
Service Code
|
HCPCS J9181
|
| Hospital Charge Code |
2958962
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.33
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.88
|
| Rate for Payer: Health EOS Commercial |
$24.07
|
| Rate for Payer: HFN Commercial |
$24.88
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: Preferred Network Access Commercial |
$24.88
|
| Rate for Payer: Quartz Beloit One Network |
$13.25
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$20.03
|
|
|
Toradol 15 mg Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Toradol 15 mg Charge
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$0.34
|
| Rate for Payer: Anthem Medicare Advantage |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.34
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.73
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.51
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: Quartz Medicare Advantage |
$0.34
|
| Rate for Payer: The Alliance Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicaid |
$0.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.34
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
|
Toradol 15 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
2958957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Anthem Medicare Advantage |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.34
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$0.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$0.34
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$0.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.51
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$0.34
|
| Rate for Payer: The Alliance Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.34
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: Wellcare Medicare |
$0.34
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
|
Toradol 30mg Vial (MED)
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
4595177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$4.99
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
Toradol 30mg Vial (MED)
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
4595177
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Aetna Managed Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.99
|
| Rate for Payer: Anthem Medicare Advantage |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.34
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$0.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$0.34
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$0.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: NAPHCARE Commercial |
$0.51
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$5.41
|
| Rate for Payer: Quartz Medicare Advantage |
$0.34
|
| Rate for Payer: The Alliance Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.34
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: Wellcare Medicare |
$0.34
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
|
Toradol JW Waste Charge
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885 JW
|
| Hospital Charge Code |
5246658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Toradol JW Waste Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885 JW
|
| Hospital Charge Code |
5246658
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.97
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
