|
.035 Zip Strait 300cm
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
1158980
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$84.45 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Aetna Managed Medicare |
$84.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$196.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$150.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$144.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.78
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$226.20
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: NAPHCARE Commercial |
$180.96
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$196.04
|
| Rate for Payer: Quartz Medicare Advantage |
$180.96
|
| Rate for Payer: The Alliance Commercial |
$150.80
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
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 |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
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 |
$96.31 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$427.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,030.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,388.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,270.32
|
| Rate for Payer: Anthem Medicare Advantage |
$427.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$427.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$427.81
|
| 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 |
$180.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$427.81
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$427.81
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,591.47
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$427.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$427.81
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$427.81
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$427.81
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$641.72
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$127.76
|
| Rate for Payer: Quartz Medicare Advantage |
$427.81
|
| Rate for Payer: The Alliance Commercial |
$1,711.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$427.81
|
| Rate for Payer: United Healthcare PPO |
$2,347.28
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: Wellcare Medicare |
$427.81
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
10FR Sheath-11CM
|
Facility
|
OP
|
$534.00
|
|
| Hospital Charge Code |
4606629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$155.50 |
| Max. Negotiated Rate |
$510.93 |
| Rate for Payer: Aetna Commercial |
$499.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$477.61
|
| Rate for Payer: Aetna Managed Medicare |
$155.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.34
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$510.93
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$310.79
|
| Rate for Payer: Health EOS Commercial |
$494.27
|
| Rate for Payer: HFN Commercial |
$510.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$416.52
|
| Rate for Payer: Multiplan Commercial |
$444.29
|
| Rate for Payer: NAPHCARE Commercial |
$333.22
|
| Rate for Payer: Preferred Network Access Commercial |
$510.93
|
| Rate for Payer: Quartz Beloit One Network |
$272.13
|
| Rate for Payer: Quartz Commercial |
$360.98
|
| Rate for Payer: Quartz Medicare Advantage |
$333.22
|
| Rate for Payer: The Alliance Commercial |
$277.68
|
| Rate for Payer: WEA Trust Commercial |
$305.45
|
| Rate for Payer: WPS Commercial |
$411.34
|
|
|
10FR Sheath-11CM
|
Facility
|
IP
|
$534.00
|
|
| Hospital Charge Code |
4606629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$272.13 |
| Max. Negotiated Rate |
$510.93 |
| Rate for Payer: Aetna Commercial |
$499.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$477.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$294.34
|
| Rate for Payer: Cash Price |
$160.20
|
| Rate for Payer: Cigna Commercial |
$510.93
|
| Rate for Payer: Health EOS Commercial |
$494.27
|
| Rate for Payer: HFN Commercial |
$510.93
|
| Rate for Payer: Multiplan Commercial |
$444.29
|
| Rate for Payer: Preferred Network Access Commercial |
$510.93
|
| Rate for Payer: Quartz Beloit One Network |
$272.13
|
| Rate for Payer: Quartz Commercial |
$333.22
|
| Rate for Payer: WEA Trust Commercial |
$305.45
|
| Rate for Payer: WPS Commercial |
$411.34
|
|
|
11-Deoxycortisol
|
Professional
|
Both
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.45 |
| Max. Negotiated Rate |
$443.61 |
| Rate for Payer: Aetna Commercial |
$443.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Aetna Managed Medicare |
$30.45
|
| Rate for Payer: Anthem Medicare Advantage |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.45
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$443.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$233.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.45
|
| Rate for Payer: Health EOS Commercial |
$424.93
|
| Rate for Payer: HFN Commercial |
$443.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$107.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$107.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.45
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: NAPHCARE Commercial |
$45.68
|
| Rate for Payer: Preferred Network Access Commercial |
$443.61
|
| Rate for Payer: Quartz Beloit One Network |
$205.46
|
| Rate for Payer: Quartz Commercial |
$266.17
|
| Rate for Payer: Quartz Medicare Advantage |
$30.45
|
| Rate for Payer: The Alliance Commercial |
$120.28
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.45
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: WPS Commercial |
$133.99
|
|
|
11-Deoxycortisol
|
Facility
|
IP
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$228.81 |
| Max. Negotiated Rate |
$429.60 |
| Rate for Payer: Aetna Commercial |
$420.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.49
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$429.60
|
| Rate for Payer: Health EOS Commercial |
$415.59
|
| Rate for Payer: HFN Commercial |
$429.60
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: Preferred Network Access Commercial |
$429.60
|
| Rate for Payer: Quartz Beloit One Network |
$228.81
|
| Rate for Payer: Quartz Commercial |
$280.18
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: WPS Commercial |
$345.86
|
|
|
11-Deoxycortisol
|
Facility
|
OP
|
$449.00
|
|
|
Service Code
|
CPT 82634
|
| Hospital Charge Code |
977763
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.45 |
| Max. Negotiated Rate |
$429.60 |
| Rate for Payer: Aetna Commercial |
$420.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$401.59
|
| Rate for Payer: Aetna Managed Medicare |
$30.45
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$114.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$53.29
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$50.55
|
| Rate for Payer: Anthem Medicare Advantage |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$247.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.45
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cash Price |
$134.70
|
| Rate for Payer: Cigna Commercial |
$429.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$261.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.45
|
| Rate for Payer: Health EOS Commercial |
$415.59
|
| Rate for Payer: HFN Commercial |
$429.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.45
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.45
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.45
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.45
|
| Rate for Payer: Multiplan Commercial |
$373.57
|
| Rate for Payer: NAPHCARE Commercial |
$45.68
|
| Rate for Payer: Preferred Network Access Commercial |
$429.60
|
| Rate for Payer: Quartz Beloit One Network |
$228.81
|
| Rate for Payer: Quartz Commercial |
$303.52
|
| Rate for Payer: Quartz Medicare Advantage |
$30.45
|
| Rate for Payer: The Alliance Commercial |
$121.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.45
|
| Rate for Payer: United Healthcare PPO |
$350.22
|
| Rate for Payer: WEA Trust Commercial |
$256.83
|
| Rate for Payer: Wellcare Medicare |
$30.45
|
| Rate for Payer: WPS Commercial |
$345.86
|
|
|
1:1 Nursing Daily - Devices and Equipment
|
Facility
|
OP
|
$1,032.00
|
|
| Hospital Charge Code |
3002388
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$300.52 |
| Max. Negotiated Rate |
$987.42 |
| Rate for Payer: Aetna Commercial |
$965.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$923.02
|
| Rate for Payer: Aetna Managed Medicare |
$300.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$697.63
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$536.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$515.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$568.84
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$987.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$600.62
|
| Rate for Payer: Health EOS Commercial |
$955.22
|
| Rate for Payer: HFN Commercial |
$987.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$804.96
|
| Rate for Payer: Multiplan Commercial |
$858.62
|
| Rate for Payer: NAPHCARE Commercial |
$643.97
|
| Rate for Payer: Preferred Network Access Commercial |
$987.42
|
| Rate for Payer: Quartz Beloit One Network |
$525.91
|
| Rate for Payer: Quartz Commercial |
$697.63
|
| Rate for Payer: Quartz Medicare Advantage |
$643.97
|
| Rate for Payer: The Alliance Commercial |
$536.64
|
| Rate for Payer: WEA Trust Commercial |
$590.30
|
| Rate for Payer: WPS Commercial |
$794.95
|
|
|
1:1 Nursing Daily - Devices and Equipment
|
Facility
|
IP
|
$1,032.00
|
|
| Hospital Charge Code |
3002388
|
|
Hospital Revenue Code
|
233
|
| Min. Negotiated Rate |
$525.91 |
| Max. Negotiated Rate |
$987.42 |
| Rate for Payer: Aetna Commercial |
$965.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$923.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$568.84
|
| Rate for Payer: Cash Price |
$309.60
|
| Rate for Payer: Cigna Commercial |
$987.42
|
| Rate for Payer: Health EOS Commercial |
$955.22
|
| Rate for Payer: HFN Commercial |
$987.42
|
| Rate for Payer: Multiplan Commercial |
$858.62
|
| Rate for Payer: Preferred Network Access Commercial |
$987.42
|
| Rate for Payer: Quartz Beloit One Network |
$525.91
|
| Rate for Payer: Quartz Commercial |
$643.97
|
| Rate for Payer: WEA Trust Commercial |
$590.30
|
| Rate for Payer: WPS Commercial |
$794.95
|
|
|
120 mg - Firmagon Charge
|
Professional
|
Both
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$739.02 |
| Rate for Payer: Aetna Commercial |
$739.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$739.02
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.53
|
| Rate for Payer: Health EOS Commercial |
$707.91
|
| Rate for Payer: HFN Commercial |
$739.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$739.02
|
| Rate for Payer: Quartz Beloit One Network |
$342.28
|
| Rate for Payer: Quartz Commercial |
$443.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$12.73
|
| Rate for Payer: United Healthcare Medicaid |
$4.63
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
120 mg - Firmagon Charge
|
Facility
|
OP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Aetna Managed Medicare |
$4.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$505.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$388.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$373.40
|
| Rate for Payer: Anthem Medicare Advantage |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.63
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.63
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.63
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: NAPHCARE Commercial |
$6.94
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$505.65
|
| Rate for Payer: Quartz Medicare Advantage |
$4.63
|
| Rate for Payer: The Alliance Commercial |
$18.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.63
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: Wellcare Medicare |
$4.63
|
| Rate for Payer: WPS Commercial |
$11.32
|
|
|
120 mg - Firmagon Charge
|
Facility
|
IP
|
$748.00
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
6183045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$381.18 |
| Max. Negotiated Rate |
$715.69 |
| Rate for Payer: Aetna Commercial |
$700.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$669.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$412.30
|
| Rate for Payer: Cash Price |
$224.40
|
| Rate for Payer: Cigna Commercial |
$715.69
|
| Rate for Payer: Health EOS Commercial |
$692.35
|
| Rate for Payer: HFN Commercial |
$715.69
|
| Rate for Payer: Multiplan Commercial |
$622.34
|
| Rate for Payer: Preferred Network Access Commercial |
$715.69
|
| Rate for Payer: Quartz Beloit One Network |
$381.18
|
| Rate for Payer: Quartz Commercial |
$466.75
|
| Rate for Payer: WEA Trust Commercial |
$427.86
|
| Rate for Payer: WPS Commercial |
$576.18
|
|
|
14.3.3 eta Protein
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$262.96
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$303.42
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
14.3.3 eta Protein
|
Professional
|
Both
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$384.33 |
| Rate for Payer: Aetna Commercial |
$384.33
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$384.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$202.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$368.15
|
| Rate for Payer: HFN Commercial |
$384.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$384.33
|
| Rate for Payer: Quartz Beloit One Network |
$178.01
|
| Rate for Payer: Quartz Commercial |
$230.60
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
14.3.3 eta Protein
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
5965630
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.23 |
| Max. Negotiated Rate |
$372.20 |
| Rate for Payer: Aetna Commercial |
$364.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$347.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.42
|
| Rate for Payer: Cash Price |
$116.70
|
| Rate for Payer: Cigna Commercial |
$372.20
|
| Rate for Payer: Health EOS Commercial |
$360.06
|
| Rate for Payer: HFN Commercial |
$372.20
|
| Rate for Payer: Multiplan Commercial |
$323.65
|
| Rate for Payer: Preferred Network Access Commercial |
$372.20
|
| Rate for Payer: Quartz Beloit One Network |
$198.23
|
| Rate for Payer: Quartz Commercial |
$242.74
|
| Rate for Payer: WEA Trust Commercial |
$222.51
|
| Rate for Payer: WPS Commercial |
$299.65
|
|
|
14 - Catheter size
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2999976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
14 - Catheter size
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2999976
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
150mm Drug Coated Balloon
|
Facility
|
IP
|
$10,539.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
4606633
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,370.67 |
| Max. Negotiated Rate |
$10,083.72 |
| Rate for Payer: Aetna Commercial |
$9,864.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,426.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,809.10
|
| Rate for Payer: Cash Price |
$3,161.70
|
| Rate for Payer: Cigna Commercial |
$10,083.72
|
| Rate for Payer: Health EOS Commercial |
$9,754.90
|
| Rate for Payer: HFN Commercial |
$10,083.72
|
| Rate for Payer: Multiplan Commercial |
$8,768.45
|
| Rate for Payer: Preferred Network Access Commercial |
$10,083.72
|
| Rate for Payer: Quartz Beloit One Network |
$5,370.67
|
| Rate for Payer: Quartz Commercial |
$6,576.34
|
| Rate for Payer: WEA Trust Commercial |
$6,028.31
|
| Rate for Payer: WPS Commercial |
$8,118.19
|
|
|
150mm Drug Coated Balloon
|
Facility
|
OP
|
$10,539.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
4606633
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,068.96 |
| Max. Negotiated Rate |
$10,083.72 |
| Rate for Payer: Aetna Commercial |
$9,864.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,426.08
|
| Rate for Payer: Aetna Managed Medicare |
$3,068.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,124.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,480.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,261.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,809.10
|
| Rate for Payer: Cash Price |
$3,161.70
|
| Rate for Payer: Cigna Commercial |
$10,083.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,133.70
|
| Rate for Payer: Health EOS Commercial |
$9,754.90
|
| Rate for Payer: HFN Commercial |
$10,083.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,220.42
|
| Rate for Payer: Multiplan Commercial |
$8,768.45
|
| Rate for Payer: NAPHCARE Commercial |
$6,576.34
|
| Rate for Payer: Preferred Network Access Commercial |
$10,083.72
|
| Rate for Payer: Quartz Beloit One Network |
$5,370.67
|
| Rate for Payer: Quartz Commercial |
$7,124.36
|
| Rate for Payer: Quartz Medicare Advantage |
$6,576.34
|
| Rate for Payer: The Alliance Commercial |
$5,480.28
|
| Rate for Payer: WEA Trust Commercial |
$6,028.31
|
| Rate for Payer: WPS Commercial |
$8,118.19
|
|
|
15 Gtts/Mi Tubing
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
3040290
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
15 Gtts/Mi Tubing
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
3040290
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
1.5 hour - Respiratory Therapy Treatment Duration
|
Facility
|
IP
|
$773.00
|
|
| Hospital Charge Code |
3023875
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$393.92 |
| Max. Negotiated Rate |
$739.61 |
| Rate for Payer: Aetna Commercial |
$723.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$691.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$426.08
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$739.61
|
| Rate for Payer: Health EOS Commercial |
$715.49
|
| Rate for Payer: HFN Commercial |
$739.61
|
| Rate for Payer: Multiplan Commercial |
$643.14
|
| Rate for Payer: Preferred Network Access Commercial |
$739.61
|
| Rate for Payer: Quartz Beloit One Network |
$393.92
|
| Rate for Payer: Quartz Commercial |
$482.35
|
| Rate for Payer: WEA Trust Commercial |
$442.16
|
| Rate for Payer: WPS Commercial |
$595.44
|
|
|
1.5 hour - Respiratory Therapy Treatment Duration
|
Facility
|
OP
|
$773.00
|
|
| Hospital Charge Code |
3023875
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$225.10 |
| Max. Negotiated Rate |
$739.61 |
| Rate for Payer: Aetna Commercial |
$723.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$691.37
|
| Rate for Payer: Aetna Managed Medicare |
$225.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$522.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$401.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$385.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$426.08
|
| Rate for Payer: Cash Price |
$231.90
|
| Rate for Payer: Cigna Commercial |
$739.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$449.89
|
| Rate for Payer: Health EOS Commercial |
$715.49
|
| Rate for Payer: HFN Commercial |
$739.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$602.94
|
| Rate for Payer: Multiplan Commercial |
$643.14
|
| Rate for Payer: NAPHCARE Commercial |
$482.35
|
| Rate for Payer: Preferred Network Access Commercial |
$739.61
|
| Rate for Payer: Quartz Beloit One Network |
$393.92
|
| Rate for Payer: Quartz Commercial |
$522.55
|
| Rate for Payer: Quartz Medicare Advantage |
$482.35
|
| Rate for Payer: The Alliance Commercial |
$401.96
|
| Rate for Payer: WEA Trust Commercial |
$442.16
|
| Rate for Payer: WPS Commercial |
$595.44
|
|
|
1.5MM EXT H-PLATE/LT 246.483
|
Facility
|
IP
|
$4,130.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
4508671
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.65 |
| Max. Negotiated Rate |
$3,951.58 |
| Rate for Payer: Aetna Commercial |
$3,865.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,693.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,276.46
|
| Rate for Payer: Cash Price |
$1,239.00
|
| Rate for Payer: Cigna Commercial |
$3,951.58
|
| Rate for Payer: Health EOS Commercial |
$3,822.73
|
| Rate for Payer: HFN Commercial |
$3,951.58
|
| Rate for Payer: Multiplan Commercial |
$3,436.16
|
| Rate for Payer: Preferred Network Access Commercial |
$3,951.58
|
| Rate for Payer: Quartz Beloit One Network |
$2,104.65
|
| Rate for Payer: Quartz Commercial |
$2,577.12
|
| Rate for Payer: WEA Trust Commercial |
$2,362.36
|
| Rate for Payer: WPS Commercial |
$3,181.34
|
|
