|
dexamethasone 1 mg Charge
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2958971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
dexamethasone 1 mg Charge
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2958971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.15
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
dexamethasone 1 mg Charge
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2958971
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.12
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone 4mg/1ml vial [Med]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2974928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$6.60
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$8.15
|
|
|
Dexamethasone 4mg/1ml vial [Med]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
2974928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$44.00 |
| Rate for Payer: Aetna Commercial |
$9.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.46
|
| Rate for Payer: Aetna Managed Medicare |
$3.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.83
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.15
|
| Rate for Payer: Health EOS Commercial |
$9.79
|
| Rate for Payer: HFN Commercial |
$10.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.25
|
| Rate for Payer: Multiplan Commercial |
$8.80
|
| Rate for Payer: NAPHCARE Commercial |
$6.60
|
| Rate for Payer: Preferred Network Access Commercial |
$10.12
|
| Rate for Payer: Quartz Beloit One Network |
$5.39
|
| Rate for Payer: Quartz Commercial |
$7.15
|
| Rate for Payer: Quartz Medicare Advantage |
$6.60
|
| Rate for Payer: The Alliance Commercial |
$44.00
|
| Rate for Payer: WEA Trust Commercial |
$6.05
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone JW Waste Charge
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J1100 JW
|
| Hospital Charge Code |
5246654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.12
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone JW Waste Charge
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J1100 JW
|
| Hospital Charge Code |
5246654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Dexamethasone JW Waste Charge
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J1100 JW
|
| Hospital Charge Code |
5246654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.15
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone Level
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256226
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.24 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$138.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$138.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$87.60
|
| Rate for Payer: Health EOS Commercial |
$132.86
|
| Rate for Payer: HFN Commercial |
$138.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: Preferred Network Access Commercial |
$138.70
|
| Rate for Payer: Quartz Beloit One Network |
$64.24
|
| Rate for Payer: Quartz Commercial |
$83.22
|
| Rate for Payer: The Alliance Commercial |
$73.00
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Dexamethasone Level
|
Facility
|
OP
|
$146.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256226
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$81.70
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$94.90
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$109.50
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Dexamethasone Level
|
Facility
|
IP
|
$146.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3256226
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.54 |
| Max. Negotiated Rate |
$134.32 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$125.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$77.38
|
| Rate for Payer: Cash Price |
$43.80
|
| Rate for Payer: Cigna Commercial |
$134.32
|
| Rate for Payer: Health EOS Commercial |
$129.94
|
| Rate for Payer: HFN Commercial |
$134.32
|
| Rate for Payer: Multiplan Commercial |
$116.80
|
| Rate for Payer: NAPHCARE Commercial |
$87.60
|
| Rate for Payer: Preferred Network Access Commercial |
$134.32
|
| Rate for Payer: Quartz Beloit One Network |
$71.54
|
| Rate for Payer: Quartz Commercial |
$87.60
|
| Rate for Payer: WEA Trust Commercial |
$80.30
|
| Rate for Payer: WPS Commercial |
$108.14
|
|
|
Dexamethasone sodium phos 1 mg J1100
|
Professional
|
Both
|
$3.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
3376948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$2.85 |
| Rate for Payer: Aetna Commercial |
$2.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.12
|
| Rate for Payer: Health EOS Commercial |
$2.73
|
| Rate for Payer: HFN Commercial |
$2.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2.85
|
| Rate for Payer: Quartz Beloit One Network |
$1.32
|
| Rate for Payer: Quartz Commercial |
$1.71
|
| Rate for Payer: The Alliance Commercial |
$1.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone sodium phos 1 mg J1100
|
Facility
|
IP
|
$3.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
3376948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.76 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.80
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$2.22
|
|
|
Dexamethasone sodium phos 1 mg J1100
|
Facility
|
OP
|
$3.00
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
3376948
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$2.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2.58
|
| Rate for Payer: Aetna Managed Medicare |
$0.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.59
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cash Price |
$0.90
|
| Rate for Payer: Cigna Commercial |
$2.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.15
|
| Rate for Payer: Health EOS Commercial |
$2.67
|
| Rate for Payer: HFN Commercial |
$2.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.25
|
| Rate for Payer: Multiplan Commercial |
$2.40
|
| Rate for Payer: NAPHCARE Commercial |
$1.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2.76
|
| Rate for Payer: Quartz Beloit One Network |
$1.47
|
| Rate for Payer: Quartz Commercial |
$1.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1.80
|
| Rate for Payer: The Alliance Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$1.65
|
| Rate for Payer: WPS Commercial |
$0.29
|
|
|
Dexamethasone Suppression Test
|
Facility
|
OP
|
$70.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
1038965
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.30 |
| Max. Negotiated Rate |
$65.20 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Aetna Managed Medicare |
$16.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$61.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.06
|
| Rate for Payer: Anthem Medicaid |
$16.84
|
| Rate for Payer: Anthem Medicare Advantage |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.30
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.17
|
| Rate for Payer: Dean Health Medicaid |
$16.84
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.30
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.30
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.30
|
| Rate for Payer: Managed Health Services Medicaid |
$17.51
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.30
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$24.45
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.84
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$45.50
|
| Rate for Payer: Quartz Medicare Advantage |
$16.30
|
| Rate for Payer: The Alliance Commercial |
$65.20
|
| Rate for Payer: United Healthcare Medicaid |
$16.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.30
|
| Rate for Payer: United Healthcare PPO |
$52.50
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: Wellcare Medicare |
$16.30
|
| Rate for Payer: WMAP Medicaid |
$16.84
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
Dexamethasone Suppression Test
|
Facility
|
IP
|
$70.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
1038965
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.30 |
| Max. Negotiated Rate |
$64.40 |
| Rate for Payer: Aetna Commercial |
$63.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$37.10
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$64.40
|
| Rate for Payer: Health EOS Commercial |
$62.30
|
| Rate for Payer: HFN Commercial |
$64.40
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: NAPHCARE Commercial |
$42.00
|
| Rate for Payer: Preferred Network Access Commercial |
$64.40
|
| Rate for Payer: Quartz Beloit One Network |
$34.30
|
| Rate for Payer: Quartz Commercial |
$42.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
Dexamethasone Suppression Test
|
Professional
|
Both
|
$70.00
|
|
|
Service Code
|
CPT 82533
|
| Hospital Charge Code |
1038965
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.80 |
| Max. Negotiated Rate |
$66.50 |
| Rate for Payer: Aetna Commercial |
$66.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$60.20
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cigna Commercial |
$66.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$35.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.00
|
| Rate for Payer: Health EOS Commercial |
$63.70
|
| Rate for Payer: HFN Commercial |
$66.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.54
|
| Rate for Payer: Multiplan Commercial |
$56.00
|
| Rate for Payer: Preferred Network Access Commercial |
$66.50
|
| Rate for Payer: Quartz Beloit One Network |
$30.80
|
| Rate for Payer: Quartz Commercial |
$39.90
|
| Rate for Payer: The Alliance Commercial |
$35.00
|
| Rate for Payer: WEA Trust Commercial |
$38.50
|
| Rate for Payer: WPS Commercial |
$51.85
|
|
|
DIABETES WITH CC
|
Facility
|
IP
|
$24,232.00
|
|
|
Service Code
|
MSDRG 638
|
| Min. Negotiated Rate |
$8,716.50 |
| Max. Negotiated Rate |
$24,232.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,716.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,882.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,472.90
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,750.20
|
| Rate for Payer: Anthem Medicare Advantage |
$8,716.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,716.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,716.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,716.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,263.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,716.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,538.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,716.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,716.50
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,716.50
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,716.50
|
| Rate for Payer: NAPHCARE Commercial |
$13,074.75
|
| Rate for Payer: Quartz Medicare Advantage |
$8,716.50
|
| Rate for Payer: The Alliance Commercial |
$24,232.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,716.50
|
| Rate for Payer: United Healthcare PPO |
$13,653.79
|
| Rate for Payer: Wellcare Medicare |
$8,716.50
|
|
|
DIABETES WITH MCC
|
Facility
|
IP
|
$38,851.00
|
|
|
Service Code
|
MSDRG 637
|
| Min. Negotiated Rate |
$13,975.35 |
| Max. Negotiated Rate |
$38,851.00 |
| Rate for Payer: Aetna Managed Medicare |
$13,975.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$30,421.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,317.45
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,153.10
|
| Rate for Payer: Anthem Medicare Advantage |
$13,975.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13,975.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13,975.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13,975.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$24,591.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13,975.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28,261.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13,975.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13,975.35
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13,975.35
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13,975.35
|
| Rate for Payer: NAPHCARE Commercial |
$20,963.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,975.35
|
| Rate for Payer: The Alliance Commercial |
$38,851.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13,975.35
|
| Rate for Payer: United Healthcare PPO |
$22,001.82
|
| Rate for Payer: Wellcare Medicare |
$13,975.35
|
|
|
DIABETES WITHOUT CC/MCC
|
Facility
|
IP
|
$16,870.00
|
|
|
Service Code
|
MSDRG 639
|
| Min. Negotiated Rate |
$6,068.42 |
| Max. Negotiated Rate |
$16,870.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,068.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,007.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,970.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,472.36
|
| Rate for Payer: Anthem Medicare Advantage |
$6,068.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,068.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,068.42
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,068.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,515.19
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,068.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,138.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,068.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,068.42
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,068.42
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,068.42
|
| Rate for Payer: NAPHCARE Commercial |
$9,102.63
|
| Rate for Payer: Quartz Medicare Advantage |
$6,068.42
|
| Rate for Payer: The Alliance Commercial |
$16,870.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,068.42
|
| Rate for Payer: United Healthcare PPO |
$9,450.17
|
| Rate for Payer: Wellcare Medicare |
$6,068.42
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$98.44 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$64.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$64.20
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Diabetic Outpatient Class (30 Min) G0109
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS G0109
|
| Hospital Charge Code |
3144169
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$29.96 |
| Max. Negotiated Rate |
$428.00 |
| Rate for Payer: Aetna Commercial |
$96.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$92.02
|
| Rate for Payer: Aetna Managed Medicare |
$29.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$56.71
|
| Rate for Payer: Cash Price |
$32.10
|
| Rate for Payer: Cigna Commercial |
$98.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$59.88
|
| Rate for Payer: Health EOS Commercial |
$95.23
|
| Rate for Payer: HFN Commercial |
$98.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.25
|
| Rate for Payer: Multiplan Commercial |
$85.60
|
| Rate for Payer: NAPHCARE Commercial |
$64.20
|
| Rate for Payer: Preferred Network Access Commercial |
$98.44
|
| Rate for Payer: Quartz Beloit One Network |
$52.43
|
| Rate for Payer: Quartz Commercial |
$69.55
|
| Rate for Payer: Quartz Medicare Advantage |
$64.20
|
| Rate for Payer: The Alliance Commercial |
$428.00
|
| Rate for Payer: United Healthcare PPO |
$80.25
|
| Rate for Payer: WEA Trust Commercial |
$58.85
|
| Rate for Payer: WPS Commercial |
$79.25
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$97.51 |
| Max. Negotiated Rate |
$183.08 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$119.40
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
Diabetic Outpatient Therapy (30 Min) G0108
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS G0108
|
| Hospital Charge Code |
3144168
|
|
Hospital Revenue Code
|
942
|
| Min. Negotiated Rate |
$55.72 |
| Max. Negotiated Rate |
$796.00 |
| Rate for Payer: Aetna Commercial |
$179.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$171.14
|
| Rate for Payer: Aetna Managed Medicare |
$55.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$129.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$99.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$95.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$105.47
|
| Rate for Payer: Cash Price |
$59.70
|
| Rate for Payer: Cigna Commercial |
$183.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.36
|
| Rate for Payer: Health EOS Commercial |
$177.11
|
| Rate for Payer: HFN Commercial |
$183.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$149.25
|
| Rate for Payer: Multiplan Commercial |
$159.20
|
| Rate for Payer: NAPHCARE Commercial |
$119.40
|
| Rate for Payer: Preferred Network Access Commercial |
$183.08
|
| Rate for Payer: Quartz Beloit One Network |
$97.51
|
| Rate for Payer: Quartz Commercial |
$129.35
|
| Rate for Payer: Quartz Medicare Advantage |
$119.40
|
| Rate for Payer: The Alliance Commercial |
$796.00
|
| Rate for Payer: United Healthcare PPO |
$149.25
|
| Rate for Payer: WEA Trust Commercial |
$109.45
|
| Rate for Payer: WPS Commercial |
$147.40
|
|
|
DIABETIC SHOE W/ROLLER/ROCKR A5503
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS A5503
|
| Hospital Charge Code |
6187266
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$38.22 |
| Max. Negotiated Rate |
$71.76 |
| Rate for Payer: Aetna Commercial |
$70.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.34
|
| Rate for Payer: Cash Price |
$23.40
|
| Rate for Payer: Cigna Commercial |
$71.76
|
| Rate for Payer: Health EOS Commercial |
$69.42
|
| Rate for Payer: HFN Commercial |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$62.40
|
| Rate for Payer: NAPHCARE Commercial |
$46.80
|
| Rate for Payer: Preferred Network Access Commercial |
$71.76
|
| Rate for Payer: Quartz Beloit One Network |
$38.22
|
| Rate for Payer: Quartz Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$42.90
|
| Rate for Payer: WPS Commercial |
$57.77
|
|
