|
Gelatein 20
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
3031434
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
Gelatein 20
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
3031434
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
Gelatein Plus
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
3031435
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
Gelatein Plus
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
3031435
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
Gelfilm Ophthalmic [Med]
|
Facility
|
OP
|
$935.00
|
|
| Hospital Charge Code |
2974939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$272.27 |
| Max. Negotiated Rate |
$894.61 |
| Rate for Payer: Aetna Commercial |
$875.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.26
|
| Rate for Payer: Aetna Managed Medicare |
$272.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$632.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$486.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$466.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.37
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$894.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$544.17
|
| Rate for Payer: Health EOS Commercial |
$865.44
|
| Rate for Payer: HFN Commercial |
$894.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$729.30
|
| Rate for Payer: Multiplan Commercial |
$777.92
|
| Rate for Payer: NAPHCARE Commercial |
$583.44
|
| Rate for Payer: Preferred Network Access Commercial |
$894.61
|
| Rate for Payer: Quartz Beloit One Network |
$476.48
|
| Rate for Payer: Quartz Commercial |
$632.06
|
| Rate for Payer: Quartz Medicare Advantage |
$583.44
|
| Rate for Payer: The Alliance Commercial |
$486.20
|
| Rate for Payer: WEA Trust Commercial |
$534.82
|
| Rate for Payer: WPS Commercial |
$720.23
|
|
|
Gelfilm Ophthalmic [Med]
|
Facility
|
IP
|
$935.00
|
|
| Hospital Charge Code |
2974939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$476.48 |
| Max. Negotiated Rate |
$894.61 |
| Rate for Payer: Aetna Commercial |
$875.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$836.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$515.37
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$894.61
|
| Rate for Payer: Health EOS Commercial |
$865.44
|
| Rate for Payer: HFN Commercial |
$894.61
|
| Rate for Payer: Multiplan Commercial |
$777.92
|
| Rate for Payer: Preferred Network Access Commercial |
$894.61
|
| Rate for Payer: Quartz Beloit One Network |
$476.48
|
| Rate for Payer: Quartz Commercial |
$583.44
|
| Rate for Payer: WEA Trust Commercial |
$534.82
|
| Rate for Payer: WPS Commercial |
$720.23
|
|
|
Gelfoam size 100 [Med]
|
Facility
|
IP
|
$144.00
|
|
| Hospital Charge Code |
2974940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$73.38 |
| Max. Negotiated Rate |
$137.78 |
| Rate for Payer: Aetna Commercial |
$134.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.37
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: Health EOS Commercial |
$133.29
|
| Rate for Payer: HFN Commercial |
$137.78
|
| Rate for Payer: Multiplan Commercial |
$119.81
|
| Rate for Payer: Preferred Network Access Commercial |
$137.78
|
| Rate for Payer: Quartz Beloit One Network |
$73.38
|
| Rate for Payer: Quartz Commercial |
$89.86
|
| Rate for Payer: WEA Trust Commercial |
$82.37
|
| Rate for Payer: WPS Commercial |
$110.92
|
|
|
Gelfoam size 100 [Med]
|
Facility
|
OP
|
$144.00
|
|
| Hospital Charge Code |
2974940
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.93 |
| Max. Negotiated Rate |
$137.78 |
| Rate for Payer: Aetna Commercial |
$134.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$128.79
|
| Rate for Payer: Aetna Managed Medicare |
$41.93
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$97.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$74.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$71.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.37
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna Commercial |
$137.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$83.81
|
| Rate for Payer: Health EOS Commercial |
$133.29
|
| Rate for Payer: HFN Commercial |
$137.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$112.32
|
| Rate for Payer: Multiplan Commercial |
$119.81
|
| Rate for Payer: NAPHCARE Commercial |
$89.86
|
| Rate for Payer: Preferred Network Access Commercial |
$137.78
|
| Rate for Payer: Quartz Beloit One Network |
$73.38
|
| Rate for Payer: Quartz Commercial |
$97.34
|
| Rate for Payer: Quartz Medicare Advantage |
$89.86
|
| Rate for Payer: The Alliance Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$82.37
|
| Rate for Payer: WPS Commercial |
$110.92
|
|
|
Gel-One Hyaluronate J7326
|
Professional
|
Both
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$543.27 |
| Max. Negotiated Rate |
$2,025.40 |
| Rate for Payer: Aetna Commercial |
$2,025.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,833.52
|
| Rate for Payer: Aetna Managed Medicare |
$549.17
|
| Rate for Payer: Anthem Medicare Advantage |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$549.17
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$2,025.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$549.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$543.27
|
| Rate for Payer: Health EOS Commercial |
$1,940.12
|
| Rate for Payer: HFN Commercial |
$2,025.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$815.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$815.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$549.17
|
| Rate for Payer: Multiplan Commercial |
$1,705.60
|
| Rate for Payer: NAPHCARE Commercial |
$823.76
|
| Rate for Payer: Preferred Network Access Commercial |
$2,025.40
|
| Rate for Payer: Quartz Beloit One Network |
$938.08
|
| Rate for Payer: Quartz Commercial |
$1,215.24
|
| Rate for Payer: Quartz Medicare Advantage |
$549.17
|
| Rate for Payer: The Alliance Commercial |
$1,510.22
|
| Rate for Payer: United Healthcare Medicaid |
$549.17
|
| Rate for Payer: United Healthcare Medicare Advantage |
$549.17
|
| Rate for Payer: WEA Trust Commercial |
$1,172.60
|
| Rate for Payer: WPS Commercial |
$1,358.16
|
|
|
Gel-One Hyaluronate J7326
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$549.17 |
| Max. Negotiated Rate |
$2,196.69 |
| Rate for Payer: Aetna Commercial |
$1,918.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,833.52
|
| Rate for Payer: Aetna Managed Medicare |
$549.17
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,385.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,066.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,023.36
|
| Rate for Payer: Anthem Medicare Advantage |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,129.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$549.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$549.17
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,961.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$549.17
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$718.73
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$549.17
|
| Rate for Payer: Health EOS Commercial |
$1,897.48
|
| Rate for Payer: HFN Commercial |
$1,961.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,042.92
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$549.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$549.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$549.17
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$549.17
|
| Rate for Payer: Multiplan Commercial |
$1,705.60
|
| Rate for Payer: NAPHCARE Commercial |
$823.76
|
| Rate for Payer: Preferred Network Access Commercial |
$1,961.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.68
|
| Rate for Payer: Quartz Commercial |
$1,385.80
|
| Rate for Payer: Quartz Medicare Advantage |
$549.17
|
| Rate for Payer: The Alliance Commercial |
$2,196.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$549.17
|
| Rate for Payer: WEA Trust Commercial |
$1,172.60
|
| Rate for Payer: Wellcare Medicare |
$549.17
|
| Rate for Payer: WPS Commercial |
$1,358.16
|
|
|
Gel-One Hyaluronate J7326
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
3397518
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,044.68 |
| Max. Negotiated Rate |
$1,961.44 |
| Rate for Payer: Aetna Commercial |
$1,918.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,833.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,129.96
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,961.44
|
| Rate for Payer: Health EOS Commercial |
$1,897.48
|
| Rate for Payer: HFN Commercial |
$1,961.44
|
| Rate for Payer: Multiplan Commercial |
$1,705.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,961.44
|
| Rate for Payer: Quartz Beloit One Network |
$1,044.68
|
| Rate for Payer: Quartz Commercial |
$1,279.20
|
| Rate for Payer: WEA Trust Commercial |
$1,172.60
|
| Rate for Payer: WPS Commercial |
$1,579.12
|
|
|
GEL PORT 120MM C8XX2
|
Facility
|
OP
|
$4,906.00
|
|
| Hospital Charge Code |
2964653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,428.63 |
| Max. Negotiated Rate |
$4,694.06 |
| Rate for Payer: Aetna Commercial |
$4,592.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,387.93
|
| Rate for Payer: Aetna Managed Medicare |
$1,428.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,316.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,551.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,449.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,704.19
|
| Rate for Payer: Cash Price |
$1,471.80
|
| Rate for Payer: Cigna Commercial |
$4,694.06
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,855.29
|
| Rate for Payer: Health EOS Commercial |
$4,540.99
|
| Rate for Payer: HFN Commercial |
$4,694.06
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,826.68
|
| Rate for Payer: Multiplan Commercial |
$4,081.79
|
| Rate for Payer: NAPHCARE Commercial |
$3,061.34
|
| Rate for Payer: Preferred Network Access Commercial |
$4,694.06
|
| Rate for Payer: Quartz Beloit One Network |
$2,500.10
|
| Rate for Payer: Quartz Commercial |
$3,316.46
|
| Rate for Payer: Quartz Medicare Advantage |
$3,061.34
|
| Rate for Payer: The Alliance Commercial |
$2,551.12
|
| Rate for Payer: WEA Trust Commercial |
$2,806.23
|
| Rate for Payer: WPS Commercial |
$3,779.09
|
|
|
GEL PORT 120MM C8XX2
|
Facility
|
IP
|
$4,906.00
|
|
| Hospital Charge Code |
2964653
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,500.10 |
| Max. Negotiated Rate |
$4,694.06 |
| Rate for Payer: Aetna Commercial |
$4,592.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,387.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,704.19
|
| Rate for Payer: Cash Price |
$1,471.80
|
| Rate for Payer: Cigna Commercial |
$4,694.06
|
| Rate for Payer: Health EOS Commercial |
$4,540.99
|
| Rate for Payer: HFN Commercial |
$4,694.06
|
| Rate for Payer: Multiplan Commercial |
$4,081.79
|
| Rate for Payer: Preferred Network Access Commercial |
$4,694.06
|
| Rate for Payer: Quartz Beloit One Network |
$2,500.10
|
| Rate for Payer: Quartz Commercial |
$3,061.34
|
| Rate for Payer: WEA Trust Commercial |
$2,806.23
|
| Rate for Payer: WPS Commercial |
$3,779.09
|
|
|
Gemzar 200 mg Charge
|
Facility
|
OP
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Aetna Managed Medicare |
$197.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$458.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$352.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$338.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.03
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$528.84
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: NAPHCARE Commercial |
$423.07
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$458.33
|
| Rate for Payer: Quartz Medicare Advantage |
$423.07
|
| Rate for Payer: The Alliance Commercial |
$14.93
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$9.50
|
|
|
Gemzar 200 mg Charge
|
Professional
|
Both
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$669.86 |
| Rate for Payer: Aetna Commercial |
$669.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Aetna Managed Medicare |
$3.73
|
| Rate for Payer: Anthem Medicare Advantage |
$3.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3.73
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$669.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.80
|
| Rate for Payer: Health EOS Commercial |
$641.66
|
| Rate for Payer: HFN Commercial |
$669.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3.73
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: NAPHCARE Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$669.86
|
| Rate for Payer: Quartz Beloit One Network |
$310.25
|
| Rate for Payer: Quartz Commercial |
$401.92
|
| Rate for Payer: Quartz Medicare Advantage |
$3.73
|
| Rate for Payer: The Alliance Commercial |
$10.27
|
| Rate for Payer: United Healthcare Medicaid |
$3.73
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3.73
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$9.50
|
|
|
Gemzar 200 mg Charge
|
Facility
|
IP
|
$678.00
|
|
|
Service Code
|
HCPCS J9201
|
| Hospital Charge Code |
2958963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$345.51 |
| Max. Negotiated Rate |
$648.71 |
| Rate for Payer: Aetna Commercial |
$634.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$606.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$373.71
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$648.71
|
| Rate for Payer: Health EOS Commercial |
$627.56
|
| Rate for Payer: HFN Commercial |
$648.71
|
| Rate for Payer: Multiplan Commercial |
$564.10
|
| Rate for Payer: Preferred Network Access Commercial |
$648.71
|
| Rate for Payer: Quartz Beloit One Network |
$345.51
|
| Rate for Payer: Quartz Commercial |
$423.07
|
| Rate for Payer: WEA Trust Commercial |
$387.82
|
| Rate for Payer: WPS Commercial |
$522.26
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$29,373.84
|
|
|
Service Code
|
APR-DRG 8512
|
| Min. Negotiated Rate |
$26,091.68 |
| Max. Negotiated Rate |
$29,373.84 |
| Rate for Payer: Anthem Medicaid |
$28,127.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$28,127.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28,127.07
|
| Rate for Payer: Dean Health Medicaid |
$28,127.07
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$26,091.68
|
| Rate for Payer: Managed Health Services Medicaid |
$29,373.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,127.07
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$28,127.07
|
| Rate for Payer: United Healthcare Medicaid |
$28,127.07
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$95,048.48
|
|
|
Service Code
|
APR-DRG 8513
|
| Min. Negotiated Rate |
$84,427.99 |
| Max. Negotiated Rate |
$95,048.48 |
| Rate for Payer: Anthem Medicaid |
$91,014.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$91,014.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91,014.16
|
| Rate for Payer: Dean Health Medicaid |
$91,014.16
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$84,427.99
|
| Rate for Payer: Managed Health Services Medicaid |
$95,048.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$91,014.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$91,014.16
|
| Rate for Payer: United Healthcare Medicaid |
$91,014.16
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$95,048.48
|
|
|
Service Code
|
APR-DRG 8514
|
| Min. Negotiated Rate |
$84,427.99 |
| Max. Negotiated Rate |
$95,048.48 |
| Rate for Payer: Anthem Medicaid |
$91,014.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$91,014.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91,014.16
|
| Rate for Payer: Dean Health Medicaid |
$91,014.16
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$84,427.99
|
| Rate for Payer: Managed Health Services Medicaid |
$95,048.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$91,014.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$91,014.16
|
| Rate for Payer: United Healthcare Medicaid |
$91,014.16
|
|
|
GENDER RELATED PROCEDURES
|
Facility
|
IP
|
$17,185.89
|
|
|
Service Code
|
APR-DRG 8511
|
| Min. Negotiated Rate |
$15,265.58 |
| Max. Negotiated Rate |
$17,185.89 |
| Rate for Payer: Anthem Medicaid |
$16,456.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,456.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,456.43
|
| Rate for Payer: Dean Health Medicaid |
$16,456.43
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,265.58
|
| Rate for Payer: Managed Health Services Medicaid |
$17,185.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,456.43
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,456.43
|
| Rate for Payer: United Healthcare Medicaid |
$16,456.43
|
|
|
GENERAL ANES - SET-UP CHARGE
|
Facility
|
OP
|
$1,737.00
|
|
| Hospital Charge Code |
4519587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$505.81 |
| Max. Negotiated Rate |
$1,661.96 |
| Rate for Payer: Aetna Commercial |
$1,625.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,553.57
|
| Rate for Payer: Aetna Managed Medicare |
$505.81
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,174.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$903.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$867.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$957.43
|
| Rate for Payer: Cash Price |
$521.10
|
| Rate for Payer: Cigna Commercial |
$1,661.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,010.93
|
| Rate for Payer: Health EOS Commercial |
$1,607.77
|
| Rate for Payer: HFN Commercial |
$1,661.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,354.86
|
| Rate for Payer: Multiplan Commercial |
$1,445.18
|
| Rate for Payer: NAPHCARE Commercial |
$1,083.89
|
| Rate for Payer: Preferred Network Access Commercial |
$1,661.96
|
| Rate for Payer: Quartz Beloit One Network |
$885.18
|
| Rate for Payer: Quartz Commercial |
$1,174.21
|
| Rate for Payer: Quartz Medicare Advantage |
$1,083.89
|
| Rate for Payer: The Alliance Commercial |
$903.24
|
| Rate for Payer: WEA Trust Commercial |
$993.56
|
| Rate for Payer: WPS Commercial |
$1,338.01
|
|
|
GENERAL ANES - SET-UP CHARGE
|
Facility
|
IP
|
$1,737.00
|
|
| Hospital Charge Code |
4519587
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$885.18 |
| Max. Negotiated Rate |
$1,661.96 |
| Rate for Payer: Aetna Commercial |
$1,625.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,553.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$957.43
|
| Rate for Payer: Cash Price |
$521.10
|
| Rate for Payer: Cigna Commercial |
$1,661.96
|
| Rate for Payer: Health EOS Commercial |
$1,607.77
|
| Rate for Payer: HFN Commercial |
$1,661.96
|
| Rate for Payer: Multiplan Commercial |
$1,445.18
|
| Rate for Payer: Preferred Network Access Commercial |
$1,661.96
|
| Rate for Payer: Quartz Beloit One Network |
$885.18
|
| Rate for Payer: Quartz Commercial |
$1,083.89
|
| Rate for Payer: WEA Trust Commercial |
$993.56
|
| Rate for Payer: WPS Commercial |
$1,338.01
|
|
|
General Health Panel
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$162.49 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Aetna Managed Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$377.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$290.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$278.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$324.76
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$435.24
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: NAPHCARE Commercial |
$348.19
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$377.21
|
| Rate for Payer: Quartz Medicare Advantage |
$348.19
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: United Healthcare PPO |
$435.24
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
General Health Panel
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$156.87 |
| Max. Negotiated Rate |
$551.30 |
| Rate for Payer: Aetna Commercial |
$551.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$551.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$290.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.19
|
| Rate for Payer: Health EOS Commercial |
$528.09
|
| Rate for Payer: HFN Commercial |
$551.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$156.87
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$551.30
|
| Rate for Payer: Quartz Beloit One Network |
$255.34
|
| Rate for Payer: Quartz Commercial |
$330.78
|
| Rate for Payer: The Alliance Commercial |
$290.16
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
|
General Health Panel
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
CPT 80050
|
| Hospital Charge Code |
3473518
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$284.36 |
| Max. Negotiated Rate |
$533.89 |
| Rate for Payer: Aetna Commercial |
$522.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$499.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$307.57
|
| Rate for Payer: Cash Price |
$167.40
|
| Rate for Payer: Cigna Commercial |
$533.89
|
| Rate for Payer: Health EOS Commercial |
$516.48
|
| Rate for Payer: HFN Commercial |
$533.89
|
| Rate for Payer: Multiplan Commercial |
$464.26
|
| Rate for Payer: Preferred Network Access Commercial |
$533.89
|
| Rate for Payer: Quartz Beloit One Network |
$284.36
|
| Rate for Payer: Quartz Commercial |
$348.19
|
| Rate for Payer: WEA Trust Commercial |
$319.18
|
| Rate for Payer: WPS Commercial |
$429.83
|
|
