|
DTIC-Dome 100 mg Charge
|
Professional
|
Both
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.84 |
| Max. Negotiated Rate |
$85.96 |
| Rate for Payer: Aetna Commercial |
$85.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Aetna Managed Medicare |
$4.28
|
| Rate for Payer: Anthem Medicare Advantage |
$4.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.28
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.84
|
| Rate for Payer: Health EOS Commercial |
$82.34
|
| Rate for Payer: HFN Commercial |
$85.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.28
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: NAPHCARE Commercial |
$6.43
|
| Rate for Payer: Preferred Network Access Commercial |
$85.96
|
| Rate for Payer: Quartz Beloit One Network |
$39.81
|
| Rate for Payer: Quartz Commercial |
$51.57
|
| Rate for Payer: Quartz Medicare Advantage |
$4.28
|
| Rate for Payer: The Alliance Commercial |
$11.78
|
| Rate for Payer: United Healthcare Medicaid |
$4.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.28
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$9.59
|
|
|
DTIC-Dome 100 mg Charge
|
Facility
|
IP
|
$87.00
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
2958922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$83.24 |
| Rate for Payer: Aetna Commercial |
$81.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.95
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$83.24
|
| Rate for Payer: Health EOS Commercial |
$80.53
|
| Rate for Payer: HFN Commercial |
$83.24
|
| Rate for Payer: Multiplan Commercial |
$72.38
|
| Rate for Payer: Preferred Network Access Commercial |
$83.24
|
| Rate for Payer: Quartz Beloit One Network |
$44.34
|
| Rate for Payer: Quartz Commercial |
$54.29
|
| Rate for Payer: WEA Trust Commercial |
$49.76
|
| Rate for Payer: WPS Commercial |
$67.02
|
|
|
Dual Lead Pacemaker 9328026
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 93280 26
|
| Hospital Charge Code |
3147557
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.68 |
| Max. Negotiated Rate |
$571.06 |
| Rate for Payer: Aetna Commercial |
$571.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.96
|
| Rate for Payer: Aetna Managed Medicare |
$37.02
|
| Rate for Payer: Anthem Medicare Advantage |
$37.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$37.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$37.02
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$571.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.02
|
| Rate for Payer: Health EOS Commercial |
$547.02
|
| Rate for Payer: HFN Commercial |
$571.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$136.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$136.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$37.02
|
| Rate for Payer: Multiplan Commercial |
$480.90
|
| Rate for Payer: NAPHCARE Commercial |
$55.54
|
| Rate for Payer: Preferred Network Access Commercial |
$571.06
|
| Rate for Payer: Quartz Beloit One Network |
$264.49
|
| Rate for Payer: Quartz Commercial |
$342.64
|
| Rate for Payer: Quartz Medicare Advantage |
$37.02
|
| Rate for Payer: The Alliance Commercial |
$140.69
|
| Rate for Payer: United Healthcare Medicaid |
$34.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$37.02
|
| Rate for Payer: WEA Trust Commercial |
$330.62
|
| Rate for Payer: WPS Commercial |
$148.10
|
|
|
Dual Lead Pacemaker System 93280
|
Professional
|
Both
|
$578.00
|
|
|
Service Code
|
CPT 93280
|
| Hospital Charge Code |
3927354
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$51.64 |
| Max. Negotiated Rate |
$571.06 |
| Rate for Payer: Aetna Commercial |
$571.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$516.96
|
| Rate for Payer: Aetna Managed Medicare |
$78.40
|
| Rate for Payer: Anthem Medicare Advantage |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$78.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$78.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cash Price |
$173.40
|
| Rate for Payer: Cigna Commercial |
$571.06
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.40
|
| Rate for Payer: Health EOS Commercial |
$547.02
|
| Rate for Payer: HFN Commercial |
$571.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$277.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$480.90
|
| Rate for Payer: NAPHCARE Commercial |
$117.59
|
| Rate for Payer: Preferred Network Access Commercial |
$571.06
|
| Rate for Payer: Quartz Beloit One Network |
$264.49
|
| Rate for Payer: Quartz Commercial |
$342.64
|
| Rate for Payer: Quartz Medicare Advantage |
$78.40
|
| Rate for Payer: The Alliance Commercial |
$297.90
|
| Rate for Payer: United Healthcare Medicaid |
$51.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$78.40
|
| Rate for Payer: WEA Trust Commercial |
$330.62
|
| Rate for Payer: WPS Commercial |
$313.58
|
|
|
DUAL MOBILITY BEARING ARTICULATION HIP SYSTEM 28MM HEAD SZ 38MM BEARING C EP-200144
|
Facility
|
IP
|
$6,306.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,213.54 |
| Max. Negotiated Rate |
$6,033.58 |
| Rate for Payer: Aetna Commercial |
$5,902.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,640.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.87
|
| Rate for Payer: Cash Price |
$1,891.80
|
| Rate for Payer: Cigna Commercial |
$6,033.58
|
| Rate for Payer: Health EOS Commercial |
$5,836.83
|
| Rate for Payer: HFN Commercial |
$6,033.58
|
| Rate for Payer: Multiplan Commercial |
$5,246.59
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.54
|
| Rate for Payer: Quartz Commercial |
$3,934.94
|
| Rate for Payer: WEA Trust Commercial |
$3,607.03
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
DUAL MOBILITY BEARING ARTICULATION HIP SYSTEM 28MM HEAD SZ 38MM BEARING C EP-200144
|
Facility
|
OP
|
$6,306.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5685736
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,836.31 |
| Max. Negotiated Rate |
$6,033.58 |
| Rate for Payer: Aetna Commercial |
$5,902.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,640.09
|
| Rate for Payer: Aetna Managed Medicare |
$1,836.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,262.86
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,279.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,147.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,475.87
|
| Rate for Payer: Cash Price |
$1,891.80
|
| Rate for Payer: Cigna Commercial |
$6,033.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,670.09
|
| Rate for Payer: Health EOS Commercial |
$5,836.83
|
| Rate for Payer: HFN Commercial |
$6,033.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,918.68
|
| Rate for Payer: Multiplan Commercial |
$5,246.59
|
| Rate for Payer: NAPHCARE Commercial |
$3,934.94
|
| Rate for Payer: Preferred Network Access Commercial |
$6,033.58
|
| Rate for Payer: Quartz Beloit One Network |
$3,213.54
|
| Rate for Payer: Quartz Commercial |
$4,262.86
|
| Rate for Payer: Quartz Medicare Advantage |
$3,934.94
|
| Rate for Payer: The Alliance Commercial |
$3,279.12
|
| Rate for Payer: WEA Trust Commercial |
$3,607.03
|
| Rate for Payer: WPS Commercial |
$4,857.51
|
|
|
Dual Sheath Snare Retrieval Kit
|
Facility
|
OP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
4534612
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.52 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Aetna Managed Medicare |
$975.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,264.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,742.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,672.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,949.70
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,613.00
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,090.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,264.60
|
| Rate for Payer: Quartz Medicare Advantage |
$2,090.40
|
| Rate for Payer: The Alliance Commercial |
$1,742.00
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
Dual Sheath Snare Retrieval Kit
|
Facility
|
IP
|
$3,350.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
4534612
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,707.16 |
| Max. Negotiated Rate |
$3,205.28 |
| Rate for Payer: Aetna Commercial |
$3,135.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,996.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,846.52
|
| Rate for Payer: Cash Price |
$1,005.00
|
| Rate for Payer: Cigna Commercial |
$3,205.28
|
| Rate for Payer: Health EOS Commercial |
$3,100.76
|
| Rate for Payer: HFN Commercial |
$3,205.28
|
| Rate for Payer: Multiplan Commercial |
$2,787.20
|
| Rate for Payer: Preferred Network Access Commercial |
$3,205.28
|
| Rate for Payer: Quartz Beloit One Network |
$1,707.16
|
| Rate for Payer: Quartz Commercial |
$2,090.40
|
| Rate for Payer: WEA Trust Commercial |
$1,916.20
|
| Rate for Payer: WPS Commercial |
$2,580.51
|
|
|
Duloxetine Level (Cymbalta)
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$220.15 |
| Max. Negotiated Rate |
$413.34 |
| Rate for Payer: Aetna Commercial |
$404.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$238.12
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$413.34
|
| Rate for Payer: Health EOS Commercial |
$399.86
|
| Rate for Payer: HFN Commercial |
$413.34
|
| Rate for Payer: Multiplan Commercial |
$359.42
|
| Rate for Payer: Preferred Network Access Commercial |
$413.34
|
| Rate for Payer: Quartz Beloit One Network |
$220.15
|
| Rate for Payer: Quartz Commercial |
$269.57
|
| Rate for Payer: WEA Trust Commercial |
$247.10
|
| Rate for Payer: WPS Commercial |
$332.77
|
|
|
Duloxetine Level (Cymbalta)
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$413.34 |
| Rate for Payer: Aetna Commercial |
$404.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.38
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$238.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$413.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$251.42
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$399.86
|
| Rate for Payer: HFN Commercial |
$413.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$359.42
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$413.34
|
| Rate for Payer: Quartz Beloit One Network |
$220.15
|
| Rate for Payer: Quartz Commercial |
$292.03
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$336.96
|
| Rate for Payer: WEA Trust Commercial |
$247.10
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$332.77
|
|
|
Duloxetine Level (Cymbalta)
|
Professional
|
Both
|
$432.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
3813052
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$426.82 |
| Rate for Payer: Aetna Commercial |
$426.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.38
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cash Price |
$129.60
|
| Rate for Payer: Cigna Commercial |
$426.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$224.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$408.84
|
| Rate for Payer: HFN Commercial |
$426.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$359.42
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$426.82
|
| Rate for Payer: Quartz Beloit One Network |
$197.68
|
| Rate for Payer: Quartz Commercial |
$256.09
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$247.10
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
DUODERM 6X7 W/BORDER SIGNAL 403332
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2963774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$95.47
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
DUODERM 6X7 W/BORDER SIGNAL 403332
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2963774
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$146.39 |
| Rate for Payer: Aetna Commercial |
$143.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.84
|
| Rate for Payer: Aetna Managed Medicare |
$44.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.33
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$146.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$89.05
|
| Rate for Payer: Health EOS Commercial |
$141.62
|
| Rate for Payer: HFN Commercial |
$146.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.34
|
| Rate for Payer: Multiplan Commercial |
$127.30
|
| Rate for Payer: NAPHCARE Commercial |
$95.47
|
| Rate for Payer: Preferred Network Access Commercial |
$146.39
|
| Rate for Payer: Quartz Beloit One Network |
$77.97
|
| Rate for Payer: Quartz Commercial |
$103.43
|
| Rate for Payer: Quartz Medicare Advantage |
$95.47
|
| Rate for Payer: The Alliance Commercial |
$79.56
|
| Rate for Payer: WEA Trust Commercial |
$87.52
|
| Rate for Payer: WPS Commercial |
$117.86
|
|
|
Duoneb 2.5 mg Charge
|
Professional
|
Both
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.37
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| 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: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Duoneb 2.5 mg Charge
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
Duoneb 2.5 mg Charge
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
2958960
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| 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: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| 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 |
$5.39
|
|
|
Duoneb - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5516920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Duoneb - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5516920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.95
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
DUOVISC HEALON GV
|
Facility
|
IP
|
$811.00
|
|
| Hospital Charge Code |
5385098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$413.29 |
| Max. Negotiated Rate |
$775.96 |
| Rate for Payer: Aetna Commercial |
$759.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$725.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$447.02
|
| Rate for Payer: Cash Price |
$243.30
|
| Rate for Payer: Cigna Commercial |
$775.96
|
| Rate for Payer: Health EOS Commercial |
$750.66
|
| Rate for Payer: HFN Commercial |
$775.96
|
| Rate for Payer: Multiplan Commercial |
$674.75
|
| Rate for Payer: Preferred Network Access Commercial |
$775.96
|
| Rate for Payer: Quartz Beloit One Network |
$413.29
|
| Rate for Payer: Quartz Commercial |
$506.06
|
| Rate for Payer: WEA Trust Commercial |
$463.89
|
| Rate for Payer: WPS Commercial |
$624.71
|
|
|
DUOVISC HEALON GV
|
Facility
|
OP
|
$811.00
|
|
| Hospital Charge Code |
5385098
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$236.16 |
| Max. Negotiated Rate |
$775.96 |
| Rate for Payer: Aetna Commercial |
$759.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$725.36
|
| Rate for Payer: Aetna Managed Medicare |
$236.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$548.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$421.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$404.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$447.02
|
| Rate for Payer: Cash Price |
$243.30
|
| Rate for Payer: Cigna Commercial |
$775.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$472.00
|
| Rate for Payer: Health EOS Commercial |
$750.66
|
| Rate for Payer: HFN Commercial |
$775.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$632.58
|
| Rate for Payer: Multiplan Commercial |
$674.75
|
| Rate for Payer: NAPHCARE Commercial |
$506.06
|
| Rate for Payer: Preferred Network Access Commercial |
$775.96
|
| Rate for Payer: Quartz Beloit One Network |
$413.29
|
| Rate for Payer: Quartz Commercial |
$548.24
|
| Rate for Payer: Quartz Medicare Advantage |
$506.06
|
| Rate for Payer: The Alliance Commercial |
$421.72
|
| Rate for Payer: WEA Trust Commercial |
$463.89
|
| Rate for Payer: WPS Commercial |
$624.71
|
|
|
Duovisc Hyaluronate Sodium Applicator [Med]
|
Facility
|
IP
|
$618.00
|
|
| Hospital Charge Code |
2974932
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$314.93 |
| Max. Negotiated Rate |
$591.30 |
| Rate for Payer: Aetna Commercial |
$578.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.64
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$591.30
|
| Rate for Payer: Health EOS Commercial |
$572.02
|
| Rate for Payer: HFN Commercial |
$591.30
|
| Rate for Payer: Multiplan Commercial |
$514.18
|
| Rate for Payer: Preferred Network Access Commercial |
$591.30
|
| Rate for Payer: Quartz Beloit One Network |
$314.93
|
| Rate for Payer: Quartz Commercial |
$385.63
|
| Rate for Payer: WEA Trust Commercial |
$353.50
|
| Rate for Payer: WPS Commercial |
$476.05
|
|
|
Duovisc Hyaluronate Sodium Applicator [Med]
|
Facility
|
OP
|
$618.00
|
|
| Hospital Charge Code |
2974932
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$179.96 |
| Max. Negotiated Rate |
$591.30 |
| Rate for Payer: Aetna Commercial |
$578.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.74
|
| Rate for Payer: Aetna Managed Medicare |
$179.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$417.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$321.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$308.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.64
|
| Rate for Payer: Cash Price |
$185.40
|
| Rate for Payer: Cigna Commercial |
$591.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$359.68
|
| Rate for Payer: Health EOS Commercial |
$572.02
|
| Rate for Payer: HFN Commercial |
$591.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$482.04
|
| Rate for Payer: Multiplan Commercial |
$514.18
|
| Rate for Payer: NAPHCARE Commercial |
$385.63
|
| Rate for Payer: Preferred Network Access Commercial |
$591.30
|
| Rate for Payer: Quartz Beloit One Network |
$314.93
|
| Rate for Payer: Quartz Commercial |
$417.77
|
| Rate for Payer: Quartz Medicare Advantage |
$385.63
|
| Rate for Payer: The Alliance Commercial |
$321.36
|
| Rate for Payer: WEA Trust Commercial |
$353.50
|
| Rate for Payer: WPS Commercial |
$476.05
|
|
|
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 |
$1,780.03 |
| Max. Negotiated Rate |
$3,342.10 |
| Rate for Payer: Aetna Commercial |
$3,269.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,124.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,925.34
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,342.10
|
| Rate for Payer: Health EOS Commercial |
$3,233.12
|
| Rate for Payer: HFN Commercial |
$3,342.10
|
| Rate for Payer: Multiplan Commercial |
$2,906.18
|
| Rate for Payer: Preferred Network Access Commercial |
$3,342.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,780.03
|
| Rate for Payer: Quartz Commercial |
$2,179.63
|
| Rate for Payer: WEA Trust Commercial |
$1,998.00
|
| Rate for Payer: WPS Commercial |
$2,690.66
|
|
|
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 |
$1,017.16 |
| Max. Negotiated Rate |
$3,342.10 |
| Rate for Payer: Aetna Commercial |
$3,269.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,124.14
|
| Rate for Payer: Aetna Managed Medicare |
$1,017.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,361.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,816.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,743.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,925.34
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,342.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,032.93
|
| Rate for Payer: Health EOS Commercial |
$3,233.12
|
| Rate for Payer: HFN Commercial |
$3,342.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,724.54
|
| Rate for Payer: Multiplan Commercial |
$2,906.18
|
| Rate for Payer: NAPHCARE Commercial |
$2,179.63
|
| Rate for Payer: Preferred Network Access Commercial |
$3,342.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,780.03
|
| Rate for Payer: Quartz Commercial |
$2,361.27
|
| Rate for Payer: Quartz Medicare Advantage |
$2,179.63
|
| Rate for Payer: The Alliance Commercial |
$1,816.36
|
| Rate for Payer: WEA Trust Commercial |
$1,998.00
|
| Rate for Payer: WPS Commercial |
$2,690.66
|
|
|
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 |
$1,598.40 |
| Max. Negotiated Rate |
$3,451.08 |
| Rate for Payer: Aetna Commercial |
$3,451.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,124.14
|
| Rate for Payer: Cash Price |
$1,047.90
|
| Rate for Payer: Cigna Commercial |
$3,451.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,816.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,179.63
|
| Rate for Payer: Health EOS Commercial |
$3,305.78
|
| Rate for Payer: HFN Commercial |
$3,451.08
|
| Rate for Payer: Multiplan Commercial |
$2,906.18
|
| Rate for Payer: Preferred Network Access Commercial |
$3,451.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,598.40
|
| Rate for Payer: Quartz Commercial |
$2,070.65
|
| Rate for Payer: The Alliance Commercial |
$1,816.36
|
| Rate for Payer: WEA Trust Commercial |
$1,998.00
|
| Rate for Payer: WPS Commercial |
$2,690.66
|
|
