|
GLOVE GENTLE COMP.EDEMA MED/RT #A571-224
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970563
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.62
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$99.45
|
| Rate for Payer: Quartz Medicare Advantage |
$91.80
|
| Rate for Payer: The Alliance Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
GLOVE GENTLE COMP.EDEMA SM/LFT #A571-223
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.62
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$99.45
|
| Rate for Payer: Quartz Medicare Advantage |
$91.80
|
| Rate for Payer: The Alliance Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
GLOVE GENTLE COMP.EDEMA SM/LFT #A571-223
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970562
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$140.76 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$91.80
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
GLOVE GENTLE COMP.EDEMA SM/RT #A571-222
|
Facility
|
OP
|
$153.00
|
|
| Hospital Charge Code |
2970561
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Aetna Managed Medicare |
$42.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$99.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$76.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$73.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$85.62
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$114.75
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$99.45
|
| Rate for Payer: Quartz Medicare Advantage |
$91.80
|
| Rate for Payer: The Alliance Commercial |
$612.00
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
GLOVE GENTLE COMP.EDEMA SM/RT #A571-222
|
Facility
|
IP
|
$153.00
|
|
| Hospital Charge Code |
2970561
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$74.97 |
| Max. Negotiated Rate |
$140.76 |
| Rate for Payer: Aetna Commercial |
$137.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$131.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$81.09
|
| Rate for Payer: Cash Price |
$45.90
|
| Rate for Payer: Cigna Commercial |
$140.76
|
| Rate for Payer: Health EOS Commercial |
$136.17
|
| Rate for Payer: HFN Commercial |
$140.76
|
| Rate for Payer: Multiplan Commercial |
$122.40
|
| Rate for Payer: NAPHCARE Commercial |
$91.80
|
| Rate for Payer: Preferred Network Access Commercial |
$140.76
|
| Rate for Payer: Quartz Beloit One Network |
$74.97
|
| Rate for Payer: Quartz Commercial |
$91.80
|
| Rate for Payer: WEA Trust Commercial |
$84.15
|
| Rate for Payer: WPS Commercial |
$113.33
|
|
|
GLOVE GENTLE COMPRESSION RT/ME #A571-212
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
2969641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$77.91 |
| Max. Negotiated Rate |
$146.28 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$95.40
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
GLOVE GENTLE COMPRESSION RT/ME #A571-212
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
2969641
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.52 |
| Max. Negotiated Rate |
$636.00 |
| Rate for Payer: Aetna Commercial |
$143.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$136.74
|
| Rate for Payer: Aetna Managed Medicare |
$44.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$103.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$79.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$76.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$84.27
|
| Rate for Payer: Cash Price |
$47.70
|
| Rate for Payer: Cigna Commercial |
$146.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$141.51
|
| Rate for Payer: HFN Commercial |
$146.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$119.25
|
| Rate for Payer: Multiplan Commercial |
$127.20
|
| Rate for Payer: NAPHCARE Commercial |
$95.40
|
| Rate for Payer: Preferred Network Access Commercial |
$146.28
|
| Rate for Payer: Quartz Beloit One Network |
$77.91
|
| Rate for Payer: Quartz Commercial |
$103.35
|
| Rate for Payer: Quartz Medicare Advantage |
$95.40
|
| Rate for Payer: The Alliance Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$87.45
|
| Rate for Payer: WPS Commercial |
$117.77
|
|
|
GLOVES COMPRESSION W/O DARTS LG #55060703
|
Facility
|
IP
|
$780.00
|
|
| Hospital Charge Code |
2971628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$382.20 |
| Max. Negotiated Rate |
$717.60 |
| Rate for Payer: Aetna Commercial |
$702.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$670.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$413.40
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$717.60
|
| Rate for Payer: Health EOS Commercial |
$694.20
|
| Rate for Payer: HFN Commercial |
$717.60
|
| Rate for Payer: Multiplan Commercial |
$624.00
|
| Rate for Payer: NAPHCARE Commercial |
$468.00
|
| Rate for Payer: Preferred Network Access Commercial |
$717.60
|
| Rate for Payer: Quartz Beloit One Network |
$382.20
|
| Rate for Payer: Quartz Commercial |
$468.00
|
| Rate for Payer: WEA Trust Commercial |
$429.00
|
| Rate for Payer: WPS Commercial |
$577.75
|
|
|
GLOVES COMPRESSION W/O DARTS LG #55060703
|
Facility
|
OP
|
$780.00
|
|
| Hospital Charge Code |
2971628
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$218.40 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$702.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$670.80
|
| Rate for Payer: Aetna Managed Medicare |
$218.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$507.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$390.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$374.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$413.40
|
| Rate for Payer: Cash Price |
$234.00
|
| Rate for Payer: Cigna Commercial |
$717.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$436.49
|
| Rate for Payer: Health EOS Commercial |
$694.20
|
| Rate for Payer: HFN Commercial |
$717.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$585.00
|
| Rate for Payer: Multiplan Commercial |
$624.00
|
| Rate for Payer: NAPHCARE Commercial |
$468.00
|
| Rate for Payer: Preferred Network Access Commercial |
$717.60
|
| Rate for Payer: Quartz Beloit One Network |
$382.20
|
| Rate for Payer: Quartz Commercial |
$507.00
|
| Rate for Payer: Quartz Medicare Advantage |
$468.00
|
| Rate for Payer: The Alliance Commercial |
$3,120.00
|
| Rate for Payer: WEA Trust Commercial |
$429.00
|
| Rate for Payer: WPS Commercial |
$577.75
|
|
|
GLOVES COMPRESSION W/O DARTS XLG #55060704
|
Facility
|
IP
|
$769.00
|
|
| Hospital Charge Code |
2971620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$376.81 |
| Max. Negotiated Rate |
$707.48 |
| Rate for Payer: Aetna Commercial |
$692.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.57
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$707.48
|
| Rate for Payer: Health EOS Commercial |
$684.41
|
| Rate for Payer: HFN Commercial |
$707.48
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: NAPHCARE Commercial |
$461.40
|
| Rate for Payer: Preferred Network Access Commercial |
$707.48
|
| Rate for Payer: Quartz Beloit One Network |
$376.81
|
| Rate for Payer: Quartz Commercial |
$461.40
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
|
GLOVES COMPRESSION W/O DARTS XLG #55060704
|
Facility
|
OP
|
$769.00
|
|
| Hospital Charge Code |
2971620
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$215.32 |
| Max. Negotiated Rate |
$3,076.00 |
| Rate for Payer: Aetna Commercial |
$692.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$661.34
|
| Rate for Payer: Aetna Managed Medicare |
$215.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$499.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$384.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$369.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$407.57
|
| Rate for Payer: Cash Price |
$230.70
|
| Rate for Payer: Cigna Commercial |
$707.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$430.33
|
| Rate for Payer: Health EOS Commercial |
$684.41
|
| Rate for Payer: HFN Commercial |
$707.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$576.75
|
| Rate for Payer: Multiplan Commercial |
$615.20
|
| Rate for Payer: NAPHCARE Commercial |
$461.40
|
| Rate for Payer: Preferred Network Access Commercial |
$707.48
|
| Rate for Payer: Quartz Beloit One Network |
$376.81
|
| Rate for Payer: Quartz Commercial |
$499.85
|
| Rate for Payer: Quartz Medicare Advantage |
$461.40
|
| Rate for Payer: The Alliance Commercial |
$3,076.00
|
| Rate for Payer: WEA Trust Commercial |
$422.95
|
| Rate for Payer: WPS Commercial |
$569.60
|
|
|
glucagon 1 mg Charge
|
Professional
|
Both
|
$1,535.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2958930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.37 |
| Max. Negotiated Rate |
$1,458.25 |
| Rate for Payer: Aetna Commercial |
$1,458.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.10
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,458.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$188.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$191.52
|
| Rate for Payer: Health EOS Commercial |
$1,396.85
|
| Rate for Payer: HFN Commercial |
$1,458.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$297.55
|
| Rate for Payer: Multiplan Commercial |
$1,228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.25
|
| Rate for Payer: Quartz Beloit One Network |
$675.40
|
| Rate for Payer: Quartz Commercial |
$874.95
|
| Rate for Payer: The Alliance Commercial |
$767.50
|
| Rate for Payer: United Healthcare Medicaid |
$188.37
|
| Rate for Payer: WEA Trust Commercial |
$844.25
|
| Rate for Payer: WPS Commercial |
$478.80
|
|
|
glucagon 1 mg Charge
|
Facility
|
OP
|
$1,535.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2958930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.37 |
| Max. Negotiated Rate |
$1,412.20 |
| Rate for Payer: Aetna Commercial |
$1,381.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.10
|
| Rate for Payer: Aetna Managed Medicare |
$188.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$997.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$767.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$736.80
|
| Rate for Payer: Anthem Medicare Advantage |
$188.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$813.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$188.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$188.37
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,412.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$188.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$188.37
|
| Rate for Payer: Health EOS Commercial |
$1,366.15
|
| Rate for Payer: HFN Commercial |
$1,412.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$700.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$188.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$188.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$188.37
|
| Rate for Payer: Multiplan Commercial |
$1,228.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,412.20
|
| Rate for Payer: Quartz Beloit One Network |
$752.15
|
| Rate for Payer: Quartz Commercial |
$997.75
|
| Rate for Payer: Quartz Medicare Advantage |
$188.37
|
| Rate for Payer: The Alliance Commercial |
$753.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.37
|
| Rate for Payer: WEA Trust Commercial |
$844.25
|
| Rate for Payer: Wellcare Medicare |
$188.37
|
| Rate for Payer: WPS Commercial |
$478.80
|
|
|
glucagon 1 mg Charge
|
Facility
|
IP
|
$1,535.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2958930
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$752.15 |
| Max. Negotiated Rate |
$1,412.20 |
| Rate for Payer: Aetna Commercial |
$1,381.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,320.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$813.55
|
| Rate for Payer: Cash Price |
$460.50
|
| Rate for Payer: Cigna Commercial |
$1,412.20
|
| Rate for Payer: Health EOS Commercial |
$1,366.15
|
| Rate for Payer: HFN Commercial |
$1,412.20
|
| Rate for Payer: Multiplan Commercial |
$1,228.00
|
| Rate for Payer: NAPHCARE Commercial |
$921.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,412.20
|
| Rate for Payer: Quartz Beloit One Network |
$752.15
|
| Rate for Payer: Quartz Commercial |
$921.00
|
| Rate for Payer: WEA Trust Commercial |
$844.25
|
| Rate for Payer: WPS Commercial |
$1,136.97
|
|
|
Glucagon Level
|
Professional
|
Both
|
$698.00
|
|
|
Service Code
|
CPT 82943
|
| Hospital Charge Code |
633738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.44 |
| Max. Negotiated Rate |
$663.10 |
| Rate for Payer: Aetna Commercial |
$663.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.28
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$663.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$349.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$418.80
|
| Rate for Payer: Health EOS Commercial |
$635.18
|
| Rate for Payer: HFN Commercial |
$663.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.44
|
| Rate for Payer: Multiplan Commercial |
$558.40
|
| Rate for Payer: Preferred Network Access Commercial |
$663.10
|
| Rate for Payer: Quartz Beloit One Network |
$307.12
|
| Rate for Payer: Quartz Commercial |
$397.86
|
| Rate for Payer: The Alliance Commercial |
$349.00
|
| Rate for Payer: WEA Trust Commercial |
$383.90
|
| Rate for Payer: WPS Commercial |
$517.01
|
|
|
Glucagon Level
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
CPT 82943
|
| Hospital Charge Code |
633738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$342.02 |
| Max. Negotiated Rate |
$642.16 |
| Rate for Payer: Aetna Commercial |
$628.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.94
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$642.16
|
| Rate for Payer: Health EOS Commercial |
$621.22
|
| Rate for Payer: HFN Commercial |
$642.16
|
| Rate for Payer: Multiplan Commercial |
$558.40
|
| Rate for Payer: NAPHCARE Commercial |
$418.80
|
| Rate for Payer: Preferred Network Access Commercial |
$642.16
|
| Rate for Payer: Quartz Beloit One Network |
$342.02
|
| Rate for Payer: Quartz Commercial |
$418.80
|
| Rate for Payer: WEA Trust Commercial |
$383.90
|
| Rate for Payer: WPS Commercial |
$517.01
|
|
|
Glucagon Level
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
CPT 82943
|
| Hospital Charge Code |
633738
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.88 |
| Max. Negotiated Rate |
$642.16 |
| Rate for Payer: Aetna Commercial |
$628.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$600.28
|
| Rate for Payer: Aetna Managed Medicare |
$14.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.72
|
| Rate for Payer: Anthem Medicaid |
$13.88
|
| Rate for Payer: Anthem Medicare Advantage |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$369.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.29
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cash Price |
$209.40
|
| Rate for Payer: Cigna Commercial |
$642.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$390.60
|
| Rate for Payer: Dean Health Medicaid |
$13.88
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.29
|
| Rate for Payer: Health EOS Commercial |
$621.22
|
| Rate for Payer: HFN Commercial |
$642.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.29
|
| Rate for Payer: Managed Health Services Medicaid |
$14.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.29
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.29
|
| Rate for Payer: Multiplan Commercial |
$558.40
|
| Rate for Payer: NAPHCARE Commercial |
$21.44
|
| Rate for Payer: Preferred Network Access Commercial |
$642.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.88
|
| Rate for Payer: Quartz Beloit One Network |
$342.02
|
| Rate for Payer: Quartz Commercial |
$453.70
|
| Rate for Payer: Quartz Medicare Advantage |
$14.29
|
| Rate for Payer: The Alliance Commercial |
$57.16
|
| Rate for Payer: United Healthcare Medicaid |
$13.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.29
|
| Rate for Payer: United Healthcare PPO |
$523.50
|
| Rate for Payer: WEA Trust Commercial |
$383.90
|
| Rate for Payer: Wellcare Medicare |
$14.29
|
| Rate for Payer: WMAP Medicaid |
$13.88
|
| Rate for Payer: WPS Commercial |
$517.01
|
|
|
glucagon recombinant 1 mg Inj [Med]
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2983107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$588.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$1,080.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,032.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$636.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$1,104.00
|
| Rate for Payer: Health EOS Commercial |
$1,068.00
|
| Rate for Payer: HFN Commercial |
$1,104.00
|
| Rate for Payer: Multiplan Commercial |
$960.00
|
| Rate for Payer: NAPHCARE Commercial |
$720.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,104.00
|
| Rate for Payer: Quartz Beloit One Network |
$588.00
|
| Rate for Payer: Quartz Commercial |
$720.00
|
| Rate for Payer: WEA Trust Commercial |
$660.00
|
| Rate for Payer: WPS Commercial |
$888.84
|
|
|
glucagon recombinant 1 mg Inj [Med]
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
2983107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$188.37 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$1,080.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,032.00
|
| Rate for Payer: Aetna Managed Medicare |
$188.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$780.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$600.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$576.00
|
| Rate for Payer: Anthem Medicare Advantage |
$188.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$636.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$188.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$188.37
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Cigna Commercial |
$1,104.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$188.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$253.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$188.37
|
| Rate for Payer: Health EOS Commercial |
$1,068.00
|
| Rate for Payer: HFN Commercial |
$1,104.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$700.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$188.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$188.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$188.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$188.37
|
| Rate for Payer: Multiplan Commercial |
$960.00
|
| Rate for Payer: NAPHCARE Commercial |
$282.55
|
| Rate for Payer: Preferred Network Access Commercial |
$1,104.00
|
| Rate for Payer: Quartz Beloit One Network |
$588.00
|
| Rate for Payer: Quartz Commercial |
$780.00
|
| Rate for Payer: Quartz Medicare Advantage |
$188.37
|
| Rate for Payer: The Alliance Commercial |
$753.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$188.37
|
| Rate for Payer: WEA Trust Commercial |
$660.00
|
| Rate for Payer: Wellcare Medicare |
$188.37
|
| Rate for Payer: WPS Commercial |
$478.80
|
|
|
Glucerna 1.2 Rth 1000 mL
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
HCPCS B4154
|
| Hospital Charge Code |
3031436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.74 |
| Max. Negotiated Rate |
$115.92 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$75.60
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
Glucerna 1.2 Rth 1000 mL
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
HCPCS B4154
|
| Hospital Charge Code |
3031436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.28 |
| Max. Negotiated Rate |
$504.00 |
| Rate for Payer: Aetna Commercial |
$113.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.36
|
| Rate for Payer: Aetna Managed Medicare |
$35.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$63.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.78
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: Cigna Commercial |
$115.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.51
|
| Rate for Payer: Health EOS Commercial |
$112.14
|
| Rate for Payer: HFN Commercial |
$115.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.50
|
| Rate for Payer: Multiplan Commercial |
$100.80
|
| Rate for Payer: NAPHCARE Commercial |
$75.60
|
| Rate for Payer: Preferred Network Access Commercial |
$115.92
|
| Rate for Payer: Quartz Beloit One Network |
$61.74
|
| Rate for Payer: Quartz Commercial |
$81.90
|
| Rate for Payer: Quartz Medicare Advantage |
$75.60
|
| Rate for Payer: The Alliance Commercial |
$504.00
|
| Rate for Payer: WEA Trust Commercial |
$69.30
|
| Rate for Payer: WPS Commercial |
$93.33
|
|
|
Glucerna Shake
|
Facility
|
OP
|
$35.00
|
|
| Hospital Charge Code |
3031437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$140.00 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Aetna Managed Medicare |
$9.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.59
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$26.25
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$22.75
|
| Rate for Payer: Quartz Medicare Advantage |
$21.00
|
| Rate for Payer: The Alliance Commercial |
$140.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Glucerna Shake
|
Facility
|
IP
|
$35.00
|
|
| Hospital Charge Code |
3031437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.15 |
| Max. Negotiated Rate |
$32.20 |
| Rate for Payer: Aetna Commercial |
$31.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$18.55
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cigna Commercial |
$32.20
|
| Rate for Payer: Health EOS Commercial |
$31.15
|
| Rate for Payer: HFN Commercial |
$32.20
|
| Rate for Payer: Multiplan Commercial |
$28.00
|
| Rate for Payer: NAPHCARE Commercial |
$21.00
|
| Rate for Payer: Preferred Network Access Commercial |
$32.20
|
| Rate for Payer: Quartz Beloit One Network |
$17.15
|
| Rate for Payer: Quartz Commercial |
$21.00
|
| Rate for Payer: WEA Trust Commercial |
$19.25
|
| Rate for Payer: WPS Commercial |
$25.92
|
|
|
Gluc, Finger
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
979898
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
Gluc, Finger
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
CPT 82948
|
| Hospital Charge Code |
979898
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.79 |
| Max. Negotiated Rate |
$72.20 |
| Rate for Payer: Aetna Commercial |
$72.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.60
|
| Rate for Payer: Health EOS Commercial |
$69.16
|
| Rate for Payer: HFN Commercial |
$72.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.79
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.79
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: Preferred Network Access Commercial |
$72.20
|
| Rate for Payer: Quartz Beloit One Network |
$33.44
|
| Rate for Payer: Quartz Commercial |
$43.32
|
| Rate for Payer: The Alliance Commercial |
$38.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
