|
.035 Zip Strait 300cm
|
Facility
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$266.80 |
| Rate for Payer: Aetna Commercial |
$261.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.40
|
| Rate for Payer: Aetna Managed Medicare |
$81.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$188.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.70
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$266.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.28
|
| Rate for Payer: Health EOS Commercial |
$258.10
|
| Rate for Payer: HFN Commercial |
$266.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$217.50
|
| Rate for Payer: Multiplan Commercial |
$232.00
|
| Rate for Payer: NAPHCARE Commercial |
$174.00
|
| Rate for Payer: Preferred Network Access Commercial |
$266.80
|
| Rate for Payer: Quartz Beloit One Network |
$142.10
|
| Rate for Payer: Quartz Commercial |
$188.50
|
| Rate for Payer: Quartz Medicare Advantage |
$174.00
|
| Rate for Payer: WEA Trust Commercial |
$159.50
|
| Rate for Payer: WPS Commercial |
$214.80
|
|
|
10021 AP Bill Fine Needle Aspirate
|
Facility
IP
|
$189.00
|
|
|
Service Code
|
CPT 10021
|
| Hospital Charge Code |
1034028
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$92.61 |
| Max. Negotiated Rate |
$173.88 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$113.40
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$113.40
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
10021 AP Bill Fine Needle Aspirate
|
Facility
OP
|
$189.00
|
|
|
Service Code
|
CPT 10021
|
| Hospital Charge Code |
1034028
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$92.61 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.54
|
| Rate for Payer: Aetna Managed Medicare |
$394.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,914.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,297.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,183.00
|
| Rate for Payer: Anthem Medicare Advantage |
$394.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$394.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$394.12
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$173.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$394.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$394.12
|
| Rate for Payer: Health EOS Commercial |
$168.21
|
| Rate for Payer: HFN Commercial |
$173.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,466.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$394.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$394.12
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$394.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$394.12
|
| Rate for Payer: Multiplan Commercial |
$151.20
|
| Rate for Payer: NAPHCARE Commercial |
$591.18
|
| Rate for Payer: Preferred Network Access Commercial |
$173.88
|
| Rate for Payer: Quartz Beloit One Network |
$92.61
|
| Rate for Payer: Quartz Commercial |
$122.85
|
| Rate for Payer: Quartz Medicare Advantage |
$394.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$394.12
|
| Rate for Payer: United Healthcare PPO |
$2,257.00
|
| Rate for Payer: WEA Trust Commercial |
$103.95
|
| Rate for Payer: Wellcare Medicare |
$394.12
|
| Rate for Payer: WPS Commercial |
$139.99
|
|
|
10FR Sheath-11CM
|
Facility
IP
|
$534.00
|
|
| Hospital Charge Code |
4606629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.66 |
| Max. Negotiated Rate |
$491.28 |
| Rate for Payer: Aetna Commercial |
$480.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.02
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$491.28
|
| Rate for Payer: Health EOS Commercial |
$475.26
|
| Rate for Payer: HFN Commercial |
$491.28
|
| Rate for Payer: Multiplan Commercial |
$427.20
|
| Rate for Payer: NAPHCARE Commercial |
$320.40
|
| Rate for Payer: Preferred Network Access Commercial |
$491.28
|
| Rate for Payer: Quartz Beloit One Network |
$261.66
|
| Rate for Payer: Quartz Commercial |
$320.40
|
| Rate for Payer: WEA Trust Commercial |
$293.70
|
| Rate for Payer: WPS Commercial |
$395.53
|
|
|
10FR Sheath-11CM
|
Facility
OP
|
$534.00
|
|
| Hospital Charge Code |
4606629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.52 |
| Max. Negotiated Rate |
$2,136.00 |
| Rate for Payer: Aetna Commercial |
$480.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$459.24
|
| Rate for Payer: Aetna Managed Medicare |
$149.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$347.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$267.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$256.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$283.02
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$491.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$298.83
|
| Rate for Payer: Health EOS Commercial |
$475.26
|
| Rate for Payer: HFN Commercial |
$491.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$400.50
|
| Rate for Payer: Multiplan Commercial |
$427.20
|
| Rate for Payer: NAPHCARE Commercial |
$320.40
|
| Rate for Payer: Preferred Network Access Commercial |
$491.28
|
| Rate for Payer: Quartz Beloit One Network |
$261.66
|
| Rate for Payer: Quartz Commercial |
$347.10
|
| Rate for Payer: Quartz Medicare Advantage |
$320.40
|
| Rate for Payer: The Alliance Commercial |
$2,136.00
|
| Rate for Payer: WEA Trust Commercial |
$293.70
|
| Rate for Payer: WPS Commercial |
$395.53
|
|
|
11-Deoxycortisol
|
Facility
IP
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$220.01 |
| Max. Negotiated Rate |
$413.08 |
| Rate for Payer: Aetna Commercial |
$404.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.97
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$413.08
|
| Rate for Payer: Health EOS Commercial |
$399.61
|
| Rate for Payer: HFN Commercial |
$413.08
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: NAPHCARE Commercial |
$269.40
|
| Rate for Payer: Preferred Network Access Commercial |
$413.08
|
| Rate for Payer: Quartz Beloit One Network |
$220.01
|
| Rate for Payer: Quartz Commercial |
$269.40
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
11-Deoxycortisol
|
Professional
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.28 |
| Max. Negotiated Rate |
$426.55 |
| Rate for Payer: Aetna Commercial |
$426.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Aetna Managed Medicare |
$29.28
|
| Rate for Payer: Anthem Medicare Advantage |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.28
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$426.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$224.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.28
|
| Rate for Payer: Health EOS Commercial |
$408.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$103.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$103.36
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.28
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: Preferred Network Access Commercial |
$426.55
|
| Rate for Payer: Quartz Beloit One Network |
$197.56
|
| Rate for Payer: Quartz Commercial |
$255.93
|
| Rate for Payer: Quartz Medicare Advantage |
$29.28
|
| Rate for Payer: The Alliance Commercial |
$115.66
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.28
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: WPS Commercial |
$128.83
|
|
|
11-Deoxycortisol
|
Facility
OP
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.28 |
| Max. Negotiated Rate |
$1,796.00 |
| Rate for Payer: Aetna Commercial |
$404.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$386.14
|
| Rate for Payer: Aetna Managed Medicare |
$29.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$109.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$51.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.60
|
| Rate for Payer: Anthem Medicaid |
$30.26
|
| Rate for Payer: Anthem Medicare Advantage |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$237.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$29.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$29.28
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$413.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$29.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.26
|
| Rate for Payer: Dean Health Medicaid |
$30.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$29.28
|
| Rate for Payer: Health EOS Commercial |
$399.61
|
| Rate for Payer: HFN Commercial |
$413.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$29.28
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$29.28
|
| Rate for Payer: Managed Health Services Medicaid |
$31.47
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$29.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$29.28
|
| Rate for Payer: Multiplan Commercial |
$359.20
|
| Rate for Payer: NAPHCARE Commercial |
$43.92
|
| Rate for Payer: Preferred Network Access Commercial |
$413.08
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.26
|
| Rate for Payer: Quartz Beloit One Network |
$220.01
|
| Rate for Payer: Quartz Commercial |
$291.85
|
| Rate for Payer: Quartz Medicare Advantage |
$29.28
|
| Rate for Payer: The Alliance Commercial |
$1,796.00
|
| Rate for Payer: United Healthcare Medicaid |
$30.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$29.28
|
| Rate for Payer: United Healthcare PPO |
$336.75
|
| Rate for Payer: WEA Trust Commercial |
$246.95
|
| Rate for Payer: Wellcare Medicare |
$29.28
|
| Rate for Payer: WMAP Medicaid |
$30.26
|
| Rate for Payer: WPS Commercial |
$332.57
|
|
|
1:1 Nursing Daily - Devices and Equipment
|
Facility
OP
|
$1,032.00
|
|
| Hospital Charge Code |
3002388
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$288.96 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$928.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$887.52
|
| Rate for Payer: Aetna Managed Medicare |
$288.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$516.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$495.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.96
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$949.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$577.51
|
| Rate for Payer: Health EOS Commercial |
$918.48
|
| Rate for Payer: HFN Commercial |
$949.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$774.00
|
| Rate for Payer: Multiplan Commercial |
$825.60
|
| Rate for Payer: NAPHCARE Commercial |
$619.20
|
| Rate for Payer: Preferred Network Access Commercial |
$949.44
|
| Rate for Payer: Quartz Beloit One Network |
$505.68
|
| Rate for Payer: Quartz Commercial |
$670.80
|
| Rate for Payer: Quartz Medicare Advantage |
$619.20
|
| Rate for Payer: The Alliance Commercial |
$4,128.00
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
1:1 Nursing Daily - Devices and Equipment
|
Facility
IP
|
$1,032.00
|
|
| Hospital Charge Code |
3002388
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$505.68 |
| Max. Negotiated Rate |
$949.44 |
| Rate for Payer: Aetna Commercial |
$928.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.96
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$949.44
|
| Rate for Payer: Health EOS Commercial |
$918.48
|
| Rate for Payer: HFN Commercial |
$949.44
|
| Rate for Payer: Multiplan Commercial |
$825.60
|
| Rate for Payer: NAPHCARE Commercial |
$619.20
|
| Rate for Payer: Preferred Network Access Commercial |
$949.44
|
| Rate for Payer: Quartz Beloit One Network |
$505.68
|
| Rate for Payer: Quartz Commercial |
$619.20
|
| Rate for Payer: WEA Trust Commercial |
$567.60
|
| Rate for Payer: WPS Commercial |
$764.40
|
|
|
120 mg - Firmagon Charge
|
Facility
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$366.52 |
| Max. Negotiated Rate |
$688.16 |
| Rate for Payer: Aetna Commercial |
$673.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.44
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$688.16
|
| Rate for Payer: Health EOS Commercial |
$665.72
|
| Rate for Payer: HFN Commercial |
$688.16
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: NAPHCARE Commercial |
$448.80
|
| Rate for Payer: Preferred Network Access Commercial |
$688.16
|
| Rate for Payer: Quartz Beloit One Network |
$366.52
|
| Rate for Payer: Quartz Commercial |
$448.80
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: WPS Commercial |
$554.04
|
|
|
120 mg - Firmagon Charge
|
Facility
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$5,962.40 |
| Rate for Payer: Aetna Commercial |
$673.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.28
|
| Rate for Payer: Aetna Managed Medicare |
$4.19
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$374.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$359.04
|
| Rate for Payer: Anthem Medicare Advantage |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.19
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$688.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.19
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.19
|
| Rate for Payer: Health EOS Commercial |
$665.72
|
| Rate for Payer: HFN Commercial |
$688.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.19
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.19
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.19
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: NAPHCARE Commercial |
$6.28
|
| Rate for Payer: Preferred Network Access Commercial |
$688.16
|
| Rate for Payer: Quartz Beloit One Network |
$366.52
|
| Rate for Payer: Quartz Commercial |
$486.20
|
| Rate for Payer: Quartz Medicare Advantage |
$4.19
|
| Rate for Payer: The Alliance Commercial |
$5,962.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.19
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: Wellcare Medicare |
$4.19
|
| Rate for Payer: WPS Commercial |
$10.88
|
|
|
120 mg - Firmagon Charge
|
Professional
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$710.60 |
| Rate for Payer: Aetna Commercial |
$710.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.28
|
| Rate for Payer: Aetna Managed Medicare |
$4.19
|
| Rate for Payer: Anthem Medicare Advantage |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.19
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$710.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$374.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.35
|
| Rate for Payer: Health EOS Commercial |
$680.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.84
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.19
|
| Rate for Payer: Multiplan Commercial |
$598.40
|
| Rate for Payer: Preferred Network Access Commercial |
$710.60
|
| Rate for Payer: Quartz Beloit One Network |
$329.12
|
| Rate for Payer: Quartz Commercial |
$426.36
|
| Rate for Payer: Quartz Medicare Advantage |
$4.19
|
| Rate for Payer: The Alliance Commercial |
$11.53
|
| Rate for Payer: United Healthcare Medicaid |
$4.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.19
|
| Rate for Payer: WEA Trust Commercial |
$411.40
|
| Rate for Payer: WPS Commercial |
$10.88
|
|
|
14.3.3 eta Protein
|
Facility
IP
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$190.61 |
| Max. Negotiated Rate |
$357.88 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$233.40
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$233.40
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
14.3.3 eta Protein
|
Facility
OP
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$1,556.00 |
| Rate for Payer: Aetna Commercial |
$350.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.22
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.67
|
| Rate for Payer: Anthem Medicaid |
$17.85
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$206.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$357.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicaid |
$17.85
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$346.21
|
| Rate for Payer: HFN Commercial |
$357.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$64.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Managed Health Services Medicaid |
$18.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.27
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: NAPHCARE Commercial |
$25.90
|
| Rate for Payer: Preferred Network Access Commercial |
$357.88
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.85
|
| Rate for Payer: Quartz Beloit One Network |
$190.61
|
| Rate for Payer: Quartz Commercial |
$252.85
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$1,556.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.85
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: United Healthcare PPO |
$291.75
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: Wellcare Medicare |
$17.27
|
| Rate for Payer: WMAP Medicaid |
$17.85
|
| Rate for Payer: WPS Commercial |
$288.13
|
|
|
14.3.3 eta Protein
|
Professional
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.27 |
| Max. Negotiated Rate |
$369.55 |
| Rate for Payer: Aetna Commercial |
$369.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$334.54
|
| Rate for Payer: Aetna Managed Medicare |
$17.27
|
| Rate for Payer: Anthem Medicare Advantage |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.27
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$369.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$194.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.27
|
| Rate for Payer: Health EOS Commercial |
$353.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.27
|
| Rate for Payer: Multiplan Commercial |
$311.20
|
| Rate for Payer: Preferred Network Access Commercial |
$369.55
|
| Rate for Payer: Quartz Beloit One Network |
$171.16
|
| Rate for Payer: Quartz Commercial |
$221.73
|
| Rate for Payer: Quartz Medicare Advantage |
$17.27
|
| Rate for Payer: The Alliance Commercial |
$68.22
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.27
|
| Rate for Payer: WEA Trust Commercial |
$213.95
|
| Rate for Payer: WPS Commercial |
$75.99
|
|
|
14 - Catheter size
|
Facility
IP
|
$104.00
|
|
| Hospital Charge Code |
2999976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
14 - Catheter size
|
Facility
OP
|
$104.00
|
|
| Hospital Charge Code |
2999976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$416.00 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$58.20
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$416.00
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$77.03
|
|
|
150mm Drug Coated Balloon
|
Facility
OP
|
$10,539.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
4606633
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,950.92 |
| Max. Negotiated Rate |
$9,695.88 |
| Rate for Payer: Aetna Commercial |
$9,485.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,063.54
|
| Rate for Payer: Aetna Managed Medicare |
$2,950.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,850.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,269.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,058.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,585.67
|
| Rate for Payer: Cash Price |
$3,161.70
|
| Rate for Payer: Cigna Commercial |
$9,695.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,897.62
|
| Rate for Payer: Health EOS Commercial |
$9,379.71
|
| Rate for Payer: HFN Commercial |
$9,695.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,904.25
|
| Rate for Payer: Multiplan Commercial |
$8,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,323.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,695.88
|
| Rate for Payer: Quartz Beloit One Network |
$5,164.11
|
| Rate for Payer: Quartz Commercial |
$6,850.35
|
| Rate for Payer: Quartz Medicare Advantage |
$6,323.40
|
| Rate for Payer: WEA Trust Commercial |
$5,796.45
|
| Rate for Payer: WPS Commercial |
$7,806.24
|
|
|
150mm Drug Coated Balloon
|
Facility
IP
|
$10,539.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
4606633
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,164.11 |
| Max. Negotiated Rate |
$9,695.88 |
| Rate for Payer: Aetna Commercial |
$9,485.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,585.67
|
| Rate for Payer: Cash Price |
$3,161.70
|
| Rate for Payer: Cigna Commercial |
$9,695.88
|
| Rate for Payer: Health EOS Commercial |
$9,379.71
|
| Rate for Payer: HFN Commercial |
$9,695.88
|
| Rate for Payer: Multiplan Commercial |
$8,431.20
|
| Rate for Payer: NAPHCARE Commercial |
$6,323.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,695.88
|
| Rate for Payer: Quartz Beloit One Network |
$5,164.11
|
| Rate for Payer: Quartz Commercial |
$6,323.40
|
| Rate for Payer: WEA Trust Commercial |
$5,796.45
|
| Rate for Payer: WPS Commercial |
$7,806.24
|
|
|
15 Gtts/Mi Tubing
|
Facility
IP
|
$6.00
|
|
| Hospital Charge Code |
3040290
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
15 Gtts/Mi Tubing
|
Facility
OP
|
$6.00
|
|
| Hospital Charge Code |
3040290
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
1.5 hour - Respiratory Therapy Treatment Duration
|
Facility
OP
|
$773.00
|
|
| Hospital Charge Code |
3023875
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$216.44 |
| Max. Negotiated Rate |
$3,092.00 |
| Rate for Payer: Aetna Commercial |
$695.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$664.78
|
| Rate for Payer: Aetna Managed Medicare |
$216.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$502.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$386.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$371.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$409.69
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$711.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$432.57
|
| Rate for Payer: Health EOS Commercial |
$687.97
|
| Rate for Payer: HFN Commercial |
$711.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$579.75
|
| Rate for Payer: Multiplan Commercial |
$618.40
|
| Rate for Payer: NAPHCARE Commercial |
$463.80
|
| Rate for Payer: Preferred Network Access Commercial |
$711.16
|
| Rate for Payer: Quartz Beloit One Network |
$378.77
|
| Rate for Payer: Quartz Commercial |
$502.45
|
| Rate for Payer: Quartz Medicare Advantage |
$463.80
|
| Rate for Payer: The Alliance Commercial |
$3,092.00
|
| Rate for Payer: WEA Trust Commercial |
$425.15
|
| Rate for Payer: WPS Commercial |
$572.56
|
|
|
1.5 hour - Respiratory Therapy Treatment Duration
|
Facility
IP
|
$773.00
|
|
| Hospital Charge Code |
3023875
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$378.77 |
| Max. Negotiated Rate |
$711.16 |
| Rate for Payer: Aetna Commercial |
$695.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$409.69
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$711.16
|
| Rate for Payer: Health EOS Commercial |
$687.97
|
| Rate for Payer: HFN Commercial |
$711.16
|
| Rate for Payer: Multiplan Commercial |
$618.40
|
| Rate for Payer: NAPHCARE Commercial |
$463.80
|
| Rate for Payer: Preferred Network Access Commercial |
$711.16
|
| Rate for Payer: Quartz Beloit One Network |
$378.77
|
| Rate for Payer: Quartz Commercial |
$463.80
|
| Rate for Payer: WEA Trust Commercial |
$425.15
|
| Rate for Payer: WPS Commercial |
$572.56
|
|
|
1.5MM EXT H-PLATE/LT 246.483
|
Facility
OP
|
$4,130.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,156.40 |
| Max. Negotiated Rate |
$3,799.60 |
| Rate for Payer: Aetna Commercial |
$3,717.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,551.80
|
| Rate for Payer: Aetna Managed Medicare |
$1,156.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,684.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,065.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,982.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,188.90
|
| Rate for Payer: Cash Price |
$1,239.00
|
| Rate for Payer: Cigna Commercial |
$3,799.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,311.15
|
| Rate for Payer: Health EOS Commercial |
$3,675.70
|
| Rate for Payer: HFN Commercial |
$3,799.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,097.50
|
| Rate for Payer: Multiplan Commercial |
$3,304.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,478.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,799.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,023.70
|
| Rate for Payer: Quartz Commercial |
$2,684.50
|
| Rate for Payer: Quartz Medicare Advantage |
$2,478.00
|
| Rate for Payer: WEA Trust Commercial |
$2,271.50
|
| Rate for Payer: WPS Commercial |
$3,059.09
|
|
