|
Genesis 7mm x 18mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2546810
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
GENETIC COUNSELING
|
Facility
|
OP
|
$91.72
|
|
|
Service Code
|
EAPG 00882
|
| Min. Negotiated Rate |
$88.19 |
| Max. Negotiated Rate |
$91.72 |
| Rate for Payer: Anthem Medicaid |
$88.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$88.19
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$88.19
|
| Rate for Payer: Dean Health Medicaid |
$88.19
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$88.19
|
| Rate for Payer: Managed Health Services Medicaid |
$91.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.19
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$88.19
|
| Rate for Payer: United Healthcare Medicaid |
$88.19
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$27,707.86
|
|
|
Service Code
|
APR-DRG 4283
|
| Min. Negotiated Rate |
$24,611.85 |
| Max. Negotiated Rate |
$27,707.86 |
| Rate for Payer: Anthem Medicaid |
$26,531.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$26,531.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26,531.80
|
| Rate for Payer: Dean Health Medicaid |
$26,531.80
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24,611.85
|
| Rate for Payer: Managed Health Services Medicaid |
$27,707.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,531.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$26,531.80
|
| Rate for Payer: United Healthcare Medicaid |
$26,531.80
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$10,083.56
|
|
|
Service Code
|
APR-DRG 4282
|
| Min. Negotiated Rate |
$8,956.84 |
| Max. Negotiated Rate |
$10,083.56 |
| Rate for Payer: Anthem Medicaid |
$9,655.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,655.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,655.56
|
| Rate for Payer: Dean Health Medicaid |
$9,655.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,956.84
|
| Rate for Payer: Managed Health Services Medicaid |
$10,083.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,655.56
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,655.56
|
| Rate for Payer: United Healthcare Medicaid |
$9,655.56
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$6,488.55
|
|
|
Service Code
|
APR-DRG 4281
|
| Min. Negotiated Rate |
$5,763.53 |
| Max. Negotiated Rate |
$6,488.55 |
| Rate for Payer: Anthem Medicaid |
$6,213.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$6,213.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6,213.14
|
| Rate for Payer: Dean Health Medicaid |
$6,213.14
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,763.53
|
| Rate for Payer: Managed Health Services Medicaid |
$6,488.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,213.14
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6,213.14
|
| Rate for Payer: United Healthcare Medicaid |
$6,213.14
|
|
|
GENETIC DISORDERS
|
Facility
|
IP
|
$46,998.14
|
|
|
Service Code
|
APR-DRG 4284
|
| Min. Negotiated Rate |
$41,746.68 |
| Max. Negotiated Rate |
$46,998.14 |
| Rate for Payer: Anthem Medicaid |
$45,003.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$45,003.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45,003.31
|
| Rate for Payer: Dean Health Medicaid |
$45,003.31
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$41,746.68
|
| Rate for Payer: Managed Health Services Medicaid |
$46,998.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$45,003.31
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$45,003.31
|
| Rate for Payer: United Healthcare Medicaid |
$45,003.31
|
|
|
GENIOGLOSSUS ADVANCEMENT
|
Facility
|
OP
|
$6,808.00
|
|
| Hospital Charge Code |
2960089
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,982.49 |
| Max. Negotiated Rate |
$6,513.89 |
| Rate for Payer: Aetna Commercial |
$6,372.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,089.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,982.49
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,602.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,540.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,398.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,513.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,962.26
|
| Rate for Payer: Health EOS Commercial |
$6,301.48
|
| Rate for Payer: HFN Commercial |
$6,513.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,310.24
|
| Rate for Payer: Multiplan Commercial |
$5,664.26
|
| Rate for Payer: NAPHCARE Commercial |
$4,248.19
|
| Rate for Payer: Preferred Network Access Commercial |
$6,513.89
|
| Rate for Payer: Quartz Beloit One Network |
$3,469.36
|
| Rate for Payer: Quartz Commercial |
$4,602.21
|
| Rate for Payer: Quartz Medicare Advantage |
$4,248.19
|
| Rate for Payer: The Alliance Commercial |
$3,540.16
|
| Rate for Payer: WEA Trust Commercial |
$3,894.18
|
| Rate for Payer: WPS Commercial |
$5,244.20
|
|
|
GENIOGLOSSUS ADVANCEMENT
|
Facility
|
IP
|
$6,808.00
|
|
| Hospital Charge Code |
2960089
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,469.36 |
| Max. Negotiated Rate |
$6,513.89 |
| Rate for Payer: Aetna Commercial |
$6,372.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,089.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,752.57
|
| Rate for Payer: Cash Price |
$2,042.40
|
| Rate for Payer: Cigna Commercial |
$6,513.89
|
| Rate for Payer: Health EOS Commercial |
$6,301.48
|
| Rate for Payer: HFN Commercial |
$6,513.89
|
| Rate for Payer: Multiplan Commercial |
$5,664.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,513.89
|
| Rate for Payer: Quartz Beloit One Network |
$3,469.36
|
| Rate for Payer: Quartz Commercial |
$4,248.19
|
| Rate for Payer: WEA Trust Commercial |
$3,894.18
|
| Rate for Payer: WPS Commercial |
$5,244.20
|
|
|
Genital Culture
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$31.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$39.45
|
|
|
Genital Culture
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.96 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$8.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.69
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.88
|
| Rate for Payer: Anthem Medicare Advantage |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.96
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.96
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.96
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$13.45
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$8.96
|
| Rate for Payer: The Alliance Commercial |
$35.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.96
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$8.96
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Genital Culture
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
633894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Gentamicin
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4075400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Aetna Managed Medicare |
$2.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.76
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.24
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: NAPHCARE Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$5.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.99
|
| Rate for Payer: The Alliance Commercial |
$9.03
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$7.11
|
|
|
Gentamicin
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
4075400
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$4.99
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
Gentamicin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
2974941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$18.72
|
| Rate for Payer: The Alliance Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Gentamicin 0.3% Ophth Ointment 3.5gm [Med]
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
2974941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Gentamicin 0.3% Ophth Solution 5ml [Med]
|
Facility
|
OP
|
$33.00
|
|
| Hospital Charge Code |
2974942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Aetna Managed Medicare |
$9.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.21
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.74
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: NAPHCARE Commercial |
$20.59
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$22.31
|
| Rate for Payer: Quartz Medicare Advantage |
$20.59
|
| Rate for Payer: The Alliance Commercial |
$17.16
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
Gentamicin 0.3% Ophth Solution 5ml [Med]
|
Facility
|
IP
|
$33.00
|
|
| Hospital Charge Code |
2974942
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.82 |
| Max. Negotiated Rate |
$31.57 |
| Rate for Payer: Aetna Commercial |
$30.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.19
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna Commercial |
$31.57
|
| Rate for Payer: Health EOS Commercial |
$30.54
|
| Rate for Payer: HFN Commercial |
$31.57
|
| Rate for Payer: Multiplan Commercial |
$27.46
|
| Rate for Payer: Preferred Network Access Commercial |
$31.57
|
| Rate for Payer: Quartz Beloit One Network |
$16.82
|
| Rate for Payer: Quartz Commercial |
$20.59
|
| Rate for Payer: WEA Trust Commercial |
$18.88
|
| Rate for Payer: WPS Commercial |
$25.42
|
|
|
gentamicin 30 mg Charge
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.26 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Aetna Commercial |
$8.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.26
|
| Rate for Payer: Anthem Medicare Advantage |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$2.26
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.89
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2.84
|
| Rate for Payer: Health EOS Commercial |
$8.52
|
| Rate for Payer: HFN Commercial |
$8.89
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$2.26
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$3.39
|
| Rate for Payer: Preferred Network Access Commercial |
$8.89
|
| Rate for Payer: Quartz Beloit One Network |
$4.12
|
| Rate for Payer: Quartz Commercial |
$5.34
|
| Rate for Payer: Quartz Medicare Advantage |
$2.26
|
| Rate for Payer: The Alliance Commercial |
$6.21
|
| Rate for Payer: United Healthcare Medicaid |
$2.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$2.26
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$7.11
|
|
|
gentamicin 30 mg Charge
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$9.03 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.76
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$5.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5.62
|
| Rate for Payer: The Alliance Commercial |
$9.03
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$7.11
|
|
|
gentamicin 30 mg Charge
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2958973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
Gentamicin 80mg/2ml vial [Med]
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2974943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$6.86
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$8.47
|
|
|
Gentamicin 80mg/2ml vial [Med]
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
2974943
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$10.52 |
| Rate for Payer: Aetna Commercial |
$10.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9.84
|
| Rate for Payer: Aetna Managed Medicare |
$3.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.06
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cigna Commercial |
$10.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.76
|
| Rate for Payer: Health EOS Commercial |
$10.18
|
| Rate for Payer: HFN Commercial |
$10.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8.58
|
| Rate for Payer: Multiplan Commercial |
$9.15
|
| Rate for Payer: NAPHCARE Commercial |
$6.86
|
| Rate for Payer: Preferred Network Access Commercial |
$10.52
|
| Rate for Payer: Quartz Beloit One Network |
$5.61
|
| Rate for Payer: Quartz Commercial |
$7.44
|
| Rate for Payer: Quartz Medicare Advantage |
$6.86
|
| Rate for Payer: The Alliance Commercial |
$9.03
|
| Rate for Payer: WEA Trust Commercial |
$6.29
|
| Rate for Payer: WPS Commercial |
$7.11
|
|
|
Gentamicin Kinetics
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.04 |
| Max. Negotiated Rate |
$268.74 |
| Rate for Payer: Aetna Commercial |
$268.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$17.04
|
| Rate for Payer: Anthem Medicare Advantage |
$17.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.04
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$268.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$141.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.04
|
| Rate for Payer: Health EOS Commercial |
$257.42
|
| Rate for Payer: HFN Commercial |
$268.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$60.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.04
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$25.55
|
| Rate for Payer: Preferred Network Access Commercial |
$268.74
|
| Rate for Payer: Quartz Beloit One Network |
$124.47
|
| Rate for Payer: Quartz Commercial |
$161.24
|
| Rate for Payer: Quartz Medicare Advantage |
$17.04
|
| Rate for Payer: The Alliance Commercial |
$67.29
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.04
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$74.95
|
|
|
Gentamicin Kinetics
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Gentamicin Kinetics
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
979890
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.04 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$17.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.81
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.28
|
| Rate for Payer: Anthem Medicare Advantage |
$17.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.04
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$158.30
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.04
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.04
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.04
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.04
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.04
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$25.55
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$17.04
|
| Rate for Payer: The Alliance Commercial |
$68.14
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.04
|
| Rate for Payer: United Healthcare PPO |
$212.16
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: Wellcare Medicare |
$17.04
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
