|
DUODERM 6X7 W/BORDER SIGNAL 403332
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2963774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$140.76 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$91.80
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
Duoneb 2.5 mg Charge
|
Professional
|
Both
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.20
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Duoneb 2.5 mg Charge
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Duoneb 2.5 mg Charge
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Duoneb - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5516920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Duoneb - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5516920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
DUOVISC HEALON GV
|
Facility
|
OP
|
$811.00
|
|
| Hospital Charge Code |
5385098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$227.08 |
| Max. Negotiated Rate |
$3,244.00 |
| Rate for Payer: Aetna Commercial |
$729.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.46
|
| Rate for Payer: Aetna Managed Medicare |
$227.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$527.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$405.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$389.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.83
|
| Rate for Payer: Cash Price |
$243.30
|
| Rate for Payer: Cigna Commercial |
$746.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$453.84
|
| Rate for Payer: Health EOS Commercial |
$721.79
|
| Rate for Payer: HFN Commercial |
$746.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$608.25
|
| Rate for Payer: Multiplan Commercial |
$648.80
|
| Rate for Payer: NAPHCARE Commercial |
$486.60
|
| Rate for Payer: Preferred Network Access Commercial |
$746.12
|
| Rate for Payer: Quartz Beloit One Network |
$397.39
|
| Rate for Payer: Quartz Commercial |
$527.15
|
| Rate for Payer: Quartz Medicare Advantage |
$486.60
|
| Rate for Payer: The Alliance Commercial |
$3,244.00
|
| Rate for Payer: WEA Trust Commercial |
$446.05
|
| Rate for Payer: WPS Commercial |
$600.71
|
|
|
DUOVISC HEALON GV
|
Facility
|
IP
|
$811.00
|
|
| Hospital Charge Code |
5385098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$397.39 |
| Max. Negotiated Rate |
$746.12 |
| Rate for Payer: Aetna Commercial |
$729.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$697.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$429.83
|
| Rate for Payer: Cash Price |
$243.30
|
| Rate for Payer: Cigna Commercial |
$746.12
|
| Rate for Payer: Health EOS Commercial |
$721.79
|
| Rate for Payer: HFN Commercial |
$746.12
|
| Rate for Payer: Multiplan Commercial |
$648.80
|
| Rate for Payer: NAPHCARE Commercial |
$486.60
|
| Rate for Payer: Preferred Network Access Commercial |
$746.12
|
| Rate for Payer: Quartz Beloit One Network |
$397.39
|
| Rate for Payer: Quartz Commercial |
$486.60
|
| Rate for Payer: WEA Trust Commercial |
$446.05
|
| Rate for Payer: WPS Commercial |
$600.71
|
|
|
Duovisc Hyaluronate Sodium Applicator [Med]
|
Facility
|
OP
|
$618.00
|
|
| Hospital Charge Code |
2974932
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$173.04 |
| Max. Negotiated Rate |
$2,472.00 |
| Rate for Payer: Aetna Commercial |
$556.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$531.48
|
| Rate for Payer: Aetna Managed Medicare |
$173.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$401.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$309.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$296.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$327.54
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$568.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$345.83
|
| Rate for Payer: Health EOS Commercial |
$550.02
|
| Rate for Payer: HFN Commercial |
$568.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$463.50
|
| Rate for Payer: Multiplan Commercial |
$494.40
|
| Rate for Payer: NAPHCARE Commercial |
$370.80
|
| Rate for Payer: Preferred Network Access Commercial |
$568.56
|
| Rate for Payer: Quartz Beloit One Network |
$302.82
|
| Rate for Payer: Quartz Commercial |
$401.70
|
| Rate for Payer: Quartz Medicare Advantage |
$370.80
|
| Rate for Payer: The Alliance Commercial |
$2,472.00
|
| Rate for Payer: WEA Trust Commercial |
$339.90
|
| Rate for Payer: WPS Commercial |
$457.75
|
|
|
Duovisc Hyaluronate Sodium Applicator [Med]
|
Facility
|
IP
|
$618.00
|
|
| Hospital Charge Code |
2974932
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$302.82 |
| Max. Negotiated Rate |
$568.56 |
| Rate for Payer: Aetna Commercial |
$556.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$531.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$327.54
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$568.56
|
| Rate for Payer: Health EOS Commercial |
$550.02
|
| Rate for Payer: HFN Commercial |
$568.56
|
| Rate for Payer: Multiplan Commercial |
$494.40
|
| Rate for Payer: NAPHCARE Commercial |
$370.80
|
| Rate for Payer: Preferred Network Access Commercial |
$568.56
|
| Rate for Payer: Quartz Beloit One Network |
$302.82
|
| Rate for Payer: Quartz Commercial |
$370.80
|
| Rate for Payer: WEA Trust Commercial |
$339.90
|
| Rate for Payer: WPS Commercial |
$457.75
|
|
|
Dupixent (dupilumab) 100 mg/0.67 mL subcutaneous syr
|
Professional
|
Both
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,536.92 |
| Max. Negotiated Rate |
$3,318.35 |
| Rate for Payer: Aetna Commercial |
$3,318.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,318.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,746.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,095.80
|
| Rate for Payer: Health EOS Commercial |
$3,178.63
|
| Rate for Payer: HFN Commercial |
$3,318.35
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,318.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.92
|
| Rate for Payer: Quartz Commercial |
$1,991.01
|
| Rate for Payer: The Alliance Commercial |
$1,746.50
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 100 mg/0.67 mL subcutaneous syr
|
Facility
|
OP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$978.04 |
| Max. Negotiated Rate |
$13,972.00 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Aetna Managed Medicare |
$978.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,270.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,676.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,954.68
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,619.75
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,270.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,095.80
|
| Rate for Payer: The Alliance Commercial |
$13,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 100 mg/0.67 mL subcutaneous syr
|
Facility
|
IP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,711.57 |
| Max. Negotiated Rate |
$3,213.56 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,095.80
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 200 mg/1.14 mL subcutaneous syr
|
Professional
|
Both
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,536.92 |
| Max. Negotiated Rate |
$3,318.35 |
| Rate for Payer: Aetna Commercial |
$3,318.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,318.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,746.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,095.80
|
| Rate for Payer: Health EOS Commercial |
$3,178.63
|
| Rate for Payer: HFN Commercial |
$3,318.35
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,318.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.92
|
| Rate for Payer: Quartz Commercial |
$1,991.01
|
| Rate for Payer: The Alliance Commercial |
$1,746.50
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 200 mg/1.14 mL subcutaneous syr
|
Facility
|
OP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$978.04 |
| Max. Negotiated Rate |
$13,972.00 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Aetna Managed Medicare |
$978.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,270.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,676.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,954.68
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,619.75
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,270.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,095.80
|
| Rate for Payer: The Alliance Commercial |
$13,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 200 mg/1.14 mL subcutaneous syr
|
Facility
|
IP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209323
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,711.57 |
| Max. Negotiated Rate |
$3,213.56 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,095.80
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 300 mg/2 mL subcutaneous syr
|
Facility
|
IP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,711.57 |
| Max. Negotiated Rate |
$3,213.56 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,095.80
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 300 mg/2 mL subcutaneous syr
|
Professional
|
Both
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,536.92 |
| Max. Negotiated Rate |
$3,318.35 |
| Rate for Payer: Aetna Commercial |
$3,318.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,318.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,746.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,095.80
|
| Rate for Payer: Health EOS Commercial |
$3,178.63
|
| Rate for Payer: HFN Commercial |
$3,318.35
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,318.35
|
| Rate for Payer: Quartz Beloit One Network |
$1,536.92
|
| Rate for Payer: Quartz Commercial |
$1,991.01
|
| Rate for Payer: The Alliance Commercial |
$1,746.50
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
Dupixent (dupilumab) 300 mg/2 mL subcutaneous syr
|
Facility
|
OP
|
$3,493.00
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
6209324
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$978.04 |
| Max. Negotiated Rate |
$13,972.00 |
| Rate for Payer: Aetna Commercial |
$3,143.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,003.98
|
| Rate for Payer: Aetna Managed Medicare |
$978.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,270.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,746.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,676.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,851.29
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,213.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,954.68
|
| Rate for Payer: Health EOS Commercial |
$3,108.77
|
| Rate for Payer: HFN Commercial |
$3,213.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,619.75
|
| Rate for Payer: Multiplan Commercial |
$2,794.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,095.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,213.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,711.57
|
| Rate for Payer: Quartz Commercial |
$2,270.45
|
| Rate for Payer: Quartz Medicare Advantage |
$2,095.80
|
| Rate for Payer: The Alliance Commercial |
$13,972.00
|
| Rate for Payer: WEA Trust Commercial |
$1,921.15
|
| Rate for Payer: WPS Commercial |
$2,587.27
|
|
|
DUPLEX SCAN HEMO COMPL BI STUDY 93985
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
CPT 93985
|
| Hospital Charge Code |
5565293
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.32 |
| Max. Negotiated Rate |
$903.43 |
| Rate for Payer: Aetna Commercial |
$216.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$216.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$205.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.80
|
| Rate for Payer: Health EOS Commercial |
$207.48
|
| Rate for Payer: HFN Commercial |
$216.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$903.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$903.43
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$216.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.32
|
| Rate for Payer: Quartz Commercial |
$129.96
|
| Rate for Payer: The Alliance Commercial |
$114.00
|
| Rate for Payer: United Healthcare Medicaid |
$205.14
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
DUPLEX SCAN HEMO COMPL BI STUDY 9398526
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
CPT 93985 26
|
| Hospital Charge Code |
5586204
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.32 |
| Max. Negotiated Rate |
$216.60 |
| Rate for Payer: Aetna Commercial |
$216.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$196.08
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cash Price |
$68.40
|
| Rate for Payer: Cigna Commercial |
$216.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$114.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$136.80
|
| Rate for Payer: Health EOS Commercial |
$207.48
|
| Rate for Payer: HFN Commercial |
$216.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$126.90
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$126.90
|
| Rate for Payer: Multiplan Commercial |
$182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$216.60
|
| Rate for Payer: Quartz Beloit One Network |
$100.32
|
| Rate for Payer: Quartz Commercial |
$129.96
|
| Rate for Payer: The Alliance Commercial |
$114.00
|
| Rate for Payer: WEA Trust Commercial |
$125.40
|
| Rate for Payer: WPS Commercial |
$168.88
|
|
|
Duplex scan hemo compl uni study
|
Facility
|
OP
|
$1,503.00
|
|
|
Service Code
|
CPT 93986
|
| Hospital Charge Code |
5595414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$1,382.76 |
| Rate for Payer: Aetna Commercial |
$1,352.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,292.58
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$976.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$751.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$721.44
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$796.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cigna Commercial |
$1,382.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,337.67
|
| Rate for Payer: HFN Commercial |
$1,382.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$1,202.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,382.76
|
| Rate for Payer: Quartz Beloit One Network |
$736.47
|
| Rate for Payer: Quartz Commercial |
$976.95
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$434.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$826.65
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$1,113.27
|
|
|
Duplex scan hemo compl uni study
|
Facility
|
IP
|
$1,503.00
|
|
|
Service Code
|
CPT 93986
|
| Hospital Charge Code |
5595414
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$736.47 |
| Max. Negotiated Rate |
$1,382.76 |
| Rate for Payer: Aetna Commercial |
$1,352.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,292.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$796.59
|
| Rate for Payer: Cash Price |
$450.90
|
| Rate for Payer: Cigna Commercial |
$1,382.76
|
| Rate for Payer: Health EOS Commercial |
$1,337.67
|
| Rate for Payer: HFN Commercial |
$1,382.76
|
| Rate for Payer: Multiplan Commercial |
$1,202.40
|
| Rate for Payer: NAPHCARE Commercial |
$901.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,382.76
|
| Rate for Payer: Quartz Beloit One Network |
$736.47
|
| Rate for Payer: Quartz Commercial |
$901.80
|
| Rate for Payer: WEA Trust Commercial |
$826.65
|
| Rate for Payer: WPS Commercial |
$1,113.27
|
|
|
DUPLEX SCAN HEMO COMPL UNI STUDY 93986
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 93986
|
| Hospital Charge Code |
5565307
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$522.83 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$118.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$522.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$522.83
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: United Healthcare Medicaid |
$118.55
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
|
DUPLEX SCAN HEMO COMPL UNI STUDY 9398626
|
Professional
|
Both
|
$140.00
|
|
|
Service Code
|
CPT 93986 26
|
| Hospital Charge Code |
5586205
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$133.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$120.40
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.00
|
| Rate for Payer: Health EOS Commercial |
$127.40
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$78.86
|
| Rate for Payer: Multiplan Commercial |
$112.00
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$61.60
|
| Rate for Payer: Quartz Commercial |
$79.80
|
| Rate for Payer: The Alliance Commercial |
$70.00
|
| Rate for Payer: WEA Trust Commercial |
$77.00
|
| Rate for Payer: WPS Commercial |
$103.70
|
|
