|
Eyelids; Excision of Chalazion, Single
|
Professional
|
Both
|
$452.00
|
|
|
Service Code
|
CPT 67800
|
| Hospital Charge Code |
1188895
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$429.40 |
| Rate for Payer: Aetna Commercial |
$429.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$388.72
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cash Price |
$135.60
|
| Rate for Payer: Cigna Commercial |
$429.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$66.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$271.20
|
| Rate for Payer: Health EOS Commercial |
$411.32
|
| Rate for Payer: HFN Commercial |
$429.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$345.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$345.94
|
| Rate for Payer: Multiplan Commercial |
$361.60
|
| Rate for Payer: Preferred Network Access Commercial |
$429.40
|
| Rate for Payer: Quartz Beloit One Network |
$198.88
|
| Rate for Payer: Quartz Commercial |
$257.64
|
| Rate for Payer: The Alliance Commercial |
$226.00
|
| Rate for Payer: United Healthcare Medicaid |
$66.08
|
| Rate for Payer: WEA Trust Commercial |
$248.60
|
| Rate for Payer: WPS Commercial |
$334.80
|
|
|
EYE TRAUMA, INTRAOCULAR REPAIR PROCEDURE
|
Facility
|
IP
|
$5,256.00
|
|
| Hospital Charge Code |
2960043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,575.44 |
| Max. Negotiated Rate |
$4,835.52 |
| Rate for Payer: Aetna Commercial |
$4,730.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.68
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$4,835.52
|
| Rate for Payer: Health EOS Commercial |
$4,677.84
|
| Rate for Payer: HFN Commercial |
$4,835.52
|
| Rate for Payer: Multiplan Commercial |
$4,204.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.44
|
| Rate for Payer: Quartz Commercial |
$3,153.60
|
| Rate for Payer: WEA Trust Commercial |
$2,890.80
|
| Rate for Payer: WPS Commercial |
$3,893.12
|
|
|
EYE TRAUMA, INTRAOCULAR REPAIR PROCEDURE
|
Facility
|
OP
|
$5,256.00
|
|
| Hospital Charge Code |
2960043
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,471.68 |
| Max. Negotiated Rate |
$21,024.00 |
| Rate for Payer: Aetna Commercial |
$4,730.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,520.16
|
| Rate for Payer: Aetna Managed Medicare |
$1,471.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,416.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,628.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,522.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,785.68
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$4,835.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,941.26
|
| Rate for Payer: Health EOS Commercial |
$4,677.84
|
| Rate for Payer: HFN Commercial |
$4,835.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,942.00
|
| Rate for Payer: Multiplan Commercial |
$4,204.80
|
| Rate for Payer: NAPHCARE Commercial |
$3,153.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,835.52
|
| Rate for Payer: Quartz Beloit One Network |
$2,575.44
|
| Rate for Payer: Quartz Commercial |
$3,416.40
|
| Rate for Payer: Quartz Medicare Advantage |
$3,153.60
|
| Rate for Payer: The Alliance Commercial |
$21,024.00
|
| Rate for Payer: WEA Trust Commercial |
$2,890.80
|
| Rate for Payer: WPS Commercial |
$3,893.12
|
|
|
Eylea 1 mg charge
|
Facility
|
IP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3002805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,307.32 |
| Max. Negotiated Rate |
$2,454.56 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,600.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,600.80
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$1,976.19
|
|
|
Eylea 1 mg charge
|
Facility
|
OP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3002805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.28 |
| Max. Negotiated Rate |
$3,449.12 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Aetna Managed Medicare |
$862.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,734.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,334.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,280.64
|
| Rate for Payer: Anthem Medicare Advantage |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$862.28
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$862.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$862.28
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,207.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$862.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$862.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$862.28
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,734.20
|
| Rate for Payer: Quartz Medicare Advantage |
$862.28
|
| Rate for Payer: The Alliance Commercial |
$3,449.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$862.28
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: Wellcare Medicare |
$862.28
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 1 mg charge
|
Professional
|
Both
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3002805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$841.13 |
| Max. Negotiated Rate |
$2,534.60 |
| Rate for Payer: Aetna Commercial |
$2,534.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,534.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$841.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.13
|
| Rate for Payer: Health EOS Commercial |
$2,427.88
|
| Rate for Payer: HFN Commercial |
$2,534.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,341.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,341.55
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,534.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.92
|
| Rate for Payer: Quartz Commercial |
$1,520.76
|
| Rate for Payer: The Alliance Commercial |
$1,334.00
|
| Rate for Payer: United Healthcare Medicaid |
$841.13
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 1 mg charge J0178 man
|
Facility
|
IP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3373501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,307.32 |
| Max. Negotiated Rate |
$2,454.56 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,600.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,600.80
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$1,976.19
|
|
|
Eylea 1 mg charge J0178 man
|
Facility
|
OP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3373501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.28 |
| Max. Negotiated Rate |
$3,449.12 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Aetna Managed Medicare |
$862.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,734.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,334.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,280.64
|
| Rate for Payer: Anthem Medicare Advantage |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$862.28
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$862.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$862.28
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,207.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$862.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$862.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$862.28
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,734.20
|
| Rate for Payer: Quartz Medicare Advantage |
$862.28
|
| Rate for Payer: The Alliance Commercial |
$3,449.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$862.28
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: Wellcare Medicare |
$862.28
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 1 mg charge J0178 man
|
Professional
|
Both
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
3373501
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$841.13 |
| Max. Negotiated Rate |
$2,534.60 |
| Rate for Payer: Aetna Commercial |
$2,534.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,534.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$841.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.13
|
| Rate for Payer: Health EOS Commercial |
$2,427.88
|
| Rate for Payer: HFN Commercial |
$2,534.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,341.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,341.55
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,534.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.92
|
| Rate for Payer: Quartz Commercial |
$1,520.76
|
| Rate for Payer: The Alliance Commercial |
$1,334.00
|
| Rate for Payer: United Healthcare Medicaid |
$841.13
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 1mg - Eylea Med Charge
|
Facility
|
IP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,307.32 |
| Max. Negotiated Rate |
$2,454.56 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,600.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,600.80
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$1,976.19
|
|
|
Eylea 1mg - Eylea Med Charge
|
Professional
|
Both
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$841.13 |
| Max. Negotiated Rate |
$2,534.60 |
| Rate for Payer: Aetna Commercial |
$2,534.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,534.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$841.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.13
|
| Rate for Payer: Health EOS Commercial |
$2,427.88
|
| Rate for Payer: HFN Commercial |
$2,534.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,341.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,341.55
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,534.60
|
| Rate for Payer: Quartz Beloit One Network |
$1,173.92
|
| Rate for Payer: Quartz Commercial |
$1,520.76
|
| Rate for Payer: The Alliance Commercial |
$1,334.00
|
| Rate for Payer: United Healthcare Medicaid |
$841.13
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 1mg - Eylea Med Charge
|
Facility
|
OP
|
$2,668.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230613
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.28 |
| Max. Negotiated Rate |
$3,449.12 |
| Rate for Payer: Aetna Commercial |
$2,401.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,294.48
|
| Rate for Payer: Aetna Managed Medicare |
$862.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,734.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,334.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,280.64
|
| Rate for Payer: Anthem Medicare Advantage |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,414.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$862.28
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cash Price |
$800.40
|
| Rate for Payer: Cigna Commercial |
$2,454.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$862.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$862.28
|
| Rate for Payer: Health EOS Commercial |
$2,374.52
|
| Rate for Payer: HFN Commercial |
$2,454.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,207.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$862.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$862.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$862.28
|
| Rate for Payer: Multiplan Commercial |
$2,134.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.42
|
| Rate for Payer: Preferred Network Access Commercial |
$2,454.56
|
| Rate for Payer: Quartz Beloit One Network |
$1,307.32
|
| Rate for Payer: Quartz Commercial |
$1,734.20
|
| Rate for Payer: Quartz Medicare Advantage |
$862.28
|
| Rate for Payer: The Alliance Commercial |
$3,449.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$862.28
|
| Rate for Payer: WEA Trust Commercial |
$1,467.40
|
| Rate for Payer: Wellcare Medicare |
$862.28
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 2mg - Eylea Med Charge
|
Facility
|
IP
|
$5,335.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,614.15 |
| Max. Negotiated Rate |
$4,908.20 |
| Rate for Payer: Aetna Commercial |
$4,801.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.55
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cigna Commercial |
$4,908.20
|
| Rate for Payer: Health EOS Commercial |
$4,748.15
|
| Rate for Payer: HFN Commercial |
$4,908.20
|
| Rate for Payer: Multiplan Commercial |
$4,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,201.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.15
|
| Rate for Payer: Quartz Commercial |
$3,201.00
|
| Rate for Payer: WEA Trust Commercial |
$2,934.25
|
| Rate for Payer: WPS Commercial |
$3,951.63
|
|
|
Eylea 2mg - Eylea Med Charge
|
Professional
|
Both
|
$5,335.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$841.13 |
| Max. Negotiated Rate |
$5,068.25 |
| Rate for Payer: Aetna Commercial |
$5,068.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.10
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cigna Commercial |
$5,068.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$841.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.13
|
| Rate for Payer: Health EOS Commercial |
$4,854.85
|
| Rate for Payer: HFN Commercial |
$5,068.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,341.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,341.55
|
| Rate for Payer: Multiplan Commercial |
$4,268.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,068.25
|
| Rate for Payer: Quartz Beloit One Network |
$2,347.40
|
| Rate for Payer: Quartz Commercial |
$3,040.95
|
| Rate for Payer: The Alliance Commercial |
$2,667.50
|
| Rate for Payer: United Healthcare Medicaid |
$841.13
|
| Rate for Payer: WEA Trust Commercial |
$2,934.25
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 2mg - Eylea Med Charge
|
Facility
|
OP
|
$5,335.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$862.28 |
| Max. Negotiated Rate |
$4,908.20 |
| Rate for Payer: Aetna Commercial |
$4,801.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,588.10
|
| Rate for Payer: Aetna Managed Medicare |
$862.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,467.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,667.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,560.80
|
| Rate for Payer: Anthem Medicare Advantage |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,827.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$862.28
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cash Price |
$1,600.50
|
| Rate for Payer: Cigna Commercial |
$4,908.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$862.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$862.28
|
| Rate for Payer: Health EOS Commercial |
$4,748.15
|
| Rate for Payer: HFN Commercial |
$4,908.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,207.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$862.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$862.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$862.28
|
| Rate for Payer: Multiplan Commercial |
$4,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,908.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,614.15
|
| Rate for Payer: Quartz Commercial |
$3,467.75
|
| Rate for Payer: Quartz Medicare Advantage |
$862.28
|
| Rate for Payer: The Alliance Commercial |
$3,449.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$862.28
|
| Rate for Payer: WEA Trust Commercial |
$2,934.25
|
| Rate for Payer: Wellcare Medicare |
$862.28
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea 8mg - Eylea Med Charge
|
Facility
|
IP
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,599.45 |
| Max. Negotiated Rate |
$4,880.60 |
| Rate for Payer: Aetna Commercial |
$4,774.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,562.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,811.65
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$4,880.60
|
| Rate for Payer: Health EOS Commercial |
$4,721.45
|
| Rate for Payer: HFN Commercial |
$4,880.60
|
| Rate for Payer: Multiplan Commercial |
$4,244.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,880.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,599.45
|
| Rate for Payer: Quartz Commercial |
$3,183.00
|
| Rate for Payer: WEA Trust Commercial |
$2,917.75
|
| Rate for Payer: WPS Commercial |
$3,929.41
|
|
|
Eylea 8mg - Eylea Med Charge
|
Facility
|
OP
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,485.40 |
| Max. Negotiated Rate |
$21,220.00 |
| Rate for Payer: Aetna Commercial |
$4,774.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,562.30
|
| Rate for Payer: Aetna Managed Medicare |
$1,485.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,448.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,652.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,546.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,811.65
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$4,880.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,968.68
|
| Rate for Payer: Health EOS Commercial |
$4,721.45
|
| Rate for Payer: HFN Commercial |
$4,880.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,978.75
|
| Rate for Payer: Multiplan Commercial |
$4,244.00
|
| Rate for Payer: NAPHCARE Commercial |
$3,183.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,880.60
|
| Rate for Payer: Quartz Beloit One Network |
$2,599.45
|
| Rate for Payer: Quartz Commercial |
$3,448.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3,183.00
|
| Rate for Payer: The Alliance Commercial |
$21,220.00
|
| Rate for Payer: WEA Trust Commercial |
$2,917.75
|
| Rate for Payer: WPS Commercial |
$3,929.41
|
|
|
Eylea 8mg - Eylea Med Charge
|
Professional
|
Both
|
$5,305.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
6230615
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,334.20 |
| Max. Negotiated Rate |
$5,039.75 |
| Rate for Payer: Aetna Commercial |
$5,039.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,562.30
|
| Rate for Payer: Cash Price |
$1,591.50
|
| Rate for Payer: Cigna Commercial |
$5,039.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,652.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,183.00
|
| Rate for Payer: Health EOS Commercial |
$4,827.55
|
| Rate for Payer: HFN Commercial |
$5,039.75
|
| Rate for Payer: Multiplan Commercial |
$4,244.00
|
| Rate for Payer: Preferred Network Access Commercial |
$5,039.75
|
| Rate for Payer: Quartz Beloit One Network |
$2,334.20
|
| Rate for Payer: Quartz Commercial |
$3,023.85
|
| Rate for Payer: The Alliance Commercial |
$2,652.50
|
| Rate for Payer: WEA Trust Commercial |
$2,917.75
|
| Rate for Payer: WPS Commercial |
$3,929.41
|
|
|
Eylea HD per 8mg inj J0178 man
|
Professional
|
Both
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$291.72 |
| Max. Negotiated Rate |
$2,102.82 |
| Rate for Payer: Aetna Commercial |
$629.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$570.18
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$629.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$841.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$841.13
|
| Rate for Payer: Health EOS Commercial |
$603.33
|
| Rate for Payer: HFN Commercial |
$629.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,341.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,341.55
|
| Rate for Payer: Multiplan Commercial |
$530.40
|
| Rate for Payer: Preferred Network Access Commercial |
$629.85
|
| Rate for Payer: Quartz Beloit One Network |
$291.72
|
| Rate for Payer: Quartz Commercial |
$377.91
|
| Rate for Payer: The Alliance Commercial |
$331.50
|
| Rate for Payer: United Healthcare Medicaid |
$841.13
|
| Rate for Payer: WEA Trust Commercial |
$364.65
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea HD per 8mg inj J0178 man
|
Facility
|
OP
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$318.24 |
| Max. Negotiated Rate |
$3,449.12 |
| Rate for Payer: Aetna Commercial |
$596.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$570.18
|
| Rate for Payer: Aetna Managed Medicare |
$862.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$430.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$331.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$318.24
|
| Rate for Payer: Anthem Medicare Advantage |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$351.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$862.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$862.28
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$609.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$862.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,112.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$862.28
|
| Rate for Payer: Health EOS Commercial |
$590.07
|
| Rate for Payer: HFN Commercial |
$609.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,207.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$862.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$862.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$862.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$862.28
|
| Rate for Payer: Multiplan Commercial |
$530.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,293.42
|
| Rate for Payer: Preferred Network Access Commercial |
$609.96
|
| Rate for Payer: Quartz Beloit One Network |
$324.87
|
| Rate for Payer: Quartz Commercial |
$430.95
|
| Rate for Payer: Quartz Medicare Advantage |
$862.28
|
| Rate for Payer: The Alliance Commercial |
$3,449.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$862.28
|
| Rate for Payer: WEA Trust Commercial |
$364.65
|
| Rate for Payer: Wellcare Medicare |
$862.28
|
| Rate for Payer: WPS Commercial |
$2,102.82
|
|
|
Eylea HD per 8mg inj J0178 man
|
Facility
|
IP
|
$663.00
|
|
|
Service Code
|
HCPCS J0178
|
| Hospital Charge Code |
6230373
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$324.87 |
| Max. Negotiated Rate |
$609.96 |
| Rate for Payer: Aetna Commercial |
$596.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$570.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$351.39
|
| Rate for Payer: Cash Price |
$198.90
|
| Rate for Payer: Cigna Commercial |
$609.96
|
| Rate for Payer: Health EOS Commercial |
$590.07
|
| Rate for Payer: HFN Commercial |
$609.96
|
| Rate for Payer: Multiplan Commercial |
$530.40
|
| Rate for Payer: NAPHCARE Commercial |
$397.80
|
| Rate for Payer: Preferred Network Access Commercial |
$609.96
|
| Rate for Payer: Quartz Beloit One Network |
$324.87
|
| Rate for Payer: Quartz Commercial |
$397.80
|
| Rate for Payer: WEA Trust Commercial |
$364.65
|
| Rate for Payer: WPS Commercial |
$491.08
|
|
|
FACE LIFT/RHYTIDOPLASTY/RHYTIDECTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,928.15 |
| Max. Negotiated Rate |
$3,620.20 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,361.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
FACE LIFT/RHYTIDOPLASTY/RHYTIDECTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960356
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
|
FACEMASK GI PROCEDURE 52070002
|
Facility
|
OP
|
$642.00
|
|
| Hospital Charge Code |
3511505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$179.76 |
| Max. Negotiated Rate |
$2,568.00 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.12
|
| Rate for Payer: Aetna Managed Medicare |
$179.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$417.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$321.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$308.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$359.26
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$481.50
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$417.30
|
| Rate for Payer: Quartz Medicare Advantage |
$385.20
|
| Rate for Payer: The Alliance Commercial |
$2,568.00
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
|
FACEMASK GI PROCEDURE 52070002
|
Facility
|
IP
|
$642.00
|
|
| Hospital Charge Code |
3511505
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$314.58 |
| Max. Negotiated Rate |
$590.64 |
| Rate for Payer: Aetna Commercial |
$577.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$552.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$340.26
|
| Rate for Payer: Cash Price |
$192.60
|
| Rate for Payer: Cigna Commercial |
$590.64
|
| Rate for Payer: Health EOS Commercial |
$571.38
|
| Rate for Payer: HFN Commercial |
$590.64
|
| Rate for Payer: Multiplan Commercial |
$513.60
|
| Rate for Payer: NAPHCARE Commercial |
$385.20
|
| Rate for Payer: Preferred Network Access Commercial |
$590.64
|
| Rate for Payer: Quartz Beloit One Network |
$314.58
|
| Rate for Payer: Quartz Commercial |
$385.20
|
| Rate for Payer: WEA Trust Commercial |
$353.10
|
| Rate for Payer: WPS Commercial |
$475.53
|
|
