|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$800.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Aetna Managed Medicare |
$56.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$130.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$100.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$96.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$111.92
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$150.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$130.00
|
| Rate for Payer: Quartz Medicare Advantage |
$120.00
|
| Rate for Payer: The Alliance Commercial |
$800.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$98.00 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$180.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$184.00
|
| Rate for Payer: Health EOS Commercial |
$178.00
|
| Rate for Payer: HFN Commercial |
$184.00
|
| Rate for Payer: Multiplan Commercial |
$160.00
|
| Rate for Payer: NAPHCARE Commercial |
$120.00
|
| Rate for Payer: Preferred Network Access Commercial |
$184.00
|
| Rate for Payer: Quartz Beloit One Network |
$98.00
|
| Rate for Payer: Quartz Commercial |
$120.00
|
| Rate for Payer: WEA Trust Commercial |
$110.00
|
| Rate for Payer: WPS Commercial |
$148.14
|
|
|
HYDROGEL STERILE 8gr INTRASITE
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2963182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.57 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$55.80
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
HYDROGEL STERILE 8gr INTRASITE
|
Facility
|
OP
|
$93.00
|
|
| Hospital Charge Code |
2963182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.04 |
| Max. Negotiated Rate |
$372.00 |
| Rate for Payer: Aetna Commercial |
$83.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.98
|
| Rate for Payer: Aetna Managed Medicare |
$26.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.29
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$85.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.04
|
| Rate for Payer: Health EOS Commercial |
$82.77
|
| Rate for Payer: HFN Commercial |
$85.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.75
|
| Rate for Payer: Multiplan Commercial |
$74.40
|
| Rate for Payer: NAPHCARE Commercial |
$55.80
|
| Rate for Payer: Preferred Network Access Commercial |
$85.56
|
| Rate for Payer: Quartz Beloit One Network |
$45.57
|
| Rate for Payer: Quartz Commercial |
$60.45
|
| Rate for Payer: Quartz Medicare Advantage |
$55.80
|
| Rate for Payer: The Alliance Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$51.15
|
| Rate for Payer: WPS Commercial |
$68.89
|
|
|
Hydrogen Peroxide 16oz [Med]
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2974947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Hydrogen Peroxide 16oz [Med]
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2974947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Hydromorphone Charge
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.29
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$11.89
|
|
|
Hydromorphone Charge
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.76
|
| Rate for Payer: Health EOS Commercial |
$22.75
|
| Rate for Payer: HFN Commercial |
$23.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.75
|
| Rate for Payer: Quartz Beloit One Network |
$11.00
|
| Rate for Payer: Quartz Commercial |
$14.25
|
| Rate for Payer: The Alliance Commercial |
$12.50
|
| Rate for Payer: United Healthcare Medicaid |
$4.59
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$11.89
|
|
|
Hydromorphone Charge
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
Hydromorphone Inj up to 4mg J1170
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
3605567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$23.75 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.76
|
| Rate for Payer: Health EOS Commercial |
$22.75
|
| Rate for Payer: HFN Commercial |
$23.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.95
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.75
|
| Rate for Payer: Quartz Beloit One Network |
$11.00
|
| Rate for Payer: Quartz Commercial |
$14.25
|
| Rate for Payer: The Alliance Commercial |
$12.50
|
| Rate for Payer: United Healthcare Medicaid |
$4.59
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$11.89
|
|
|
Hydromorphone Inj up to 4mg J1170
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
3605567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$7.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.29
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$15.00
|
| Rate for Payer: The Alliance Commercial |
$100.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$11.89
|
|
|
Hydromorphone Inj up to 4mg J1170
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
3605567
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.08 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$12.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Anthem Medicare Advantage |
$12.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.08
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.08
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.08
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.08
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.08
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$18.13
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$12.08
|
| Rate for Payer: The Alliance Commercial |
$48.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.08
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: Wellcare Medicare |
$12.08
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$59.85 |
| Rate for Payer: Aetna Commercial |
$59.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$59.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$31.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.80
|
| Rate for Payer: Health EOS Commercial |
$57.33
|
| Rate for Payer: HFN Commercial |
$59.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$40.66
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$40.66
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$59.85
|
| Rate for Payer: Quartz Beloit One Network |
$27.72
|
| Rate for Payer: Quartz Commercial |
$35.91
|
| Rate for Payer: The Alliance Commercial |
$31.50
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Hydroxyzine hcl inj up to 25 mg J3410 man
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3373626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$3.70
|
|
|
Hydroxyzine hcl inj up to 25 mg J3410 man
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3373626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$4.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Aetna Managed Medicare |
$1.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.65
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.35
|
| Rate for Payer: Health EOS Commercial |
$4.45
|
| Rate for Payer: HFN Commercial |
$4.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.75
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: NAPHCARE Commercial |
$3.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.60
|
| Rate for Payer: Quartz Beloit One Network |
$2.45
|
| Rate for Payer: Quartz Commercial |
$3.25
|
| Rate for Payer: Quartz Medicare Advantage |
$3.00
|
| Rate for Payer: The Alliance Commercial |
$20.00
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$34.67
|
|
|
Hydroxyzine hcl inj up to 25 mg J3410 man
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
3373626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$4.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.30
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.87
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.19
|
| Rate for Payer: Multiplan Commercial |
$4.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4.75
|
| Rate for Payer: Quartz Beloit One Network |
$2.20
|
| Rate for Payer: Quartz Commercial |
$2.85
|
| Rate for Payer: The Alliance Commercial |
$2.50
|
| Rate for Payer: United Healthcare Medicaid |
$13.87
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$34.67
|
|
|
HYDRUS MICROSTENT F00022
|
Facility
|
OP
|
$8,748.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6151653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,449.44 |
| Max. Negotiated Rate |
$34,992.00 |
| Rate for Payer: Aetna Commercial |
$7,873.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,523.28
|
| Rate for Payer: Aetna Managed Medicare |
$2,449.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,686.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,374.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,199.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,636.44
|
| Rate for Payer: Cash Price |
$2,624.40
|
| Rate for Payer: Cigna Commercial |
$8,048.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,895.38
|
| Rate for Payer: Health EOS Commercial |
$7,785.72
|
| Rate for Payer: HFN Commercial |
$8,048.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,561.00
|
| Rate for Payer: Multiplan Commercial |
$6,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,248.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,048.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,286.52
|
| Rate for Payer: Quartz Commercial |
$5,686.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5,248.80
|
| Rate for Payer: The Alliance Commercial |
$34,992.00
|
| Rate for Payer: WEA Trust Commercial |
$4,811.40
|
| Rate for Payer: WPS Commercial |
$6,479.64
|
|
|
HYDRUS MICROSTENT F00022
|
Facility
|
IP
|
$8,748.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6151653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,286.52 |
| Max. Negotiated Rate |
$8,048.16 |
| Rate for Payer: Aetna Commercial |
$7,873.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,523.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,636.44
|
| Rate for Payer: Cash Price |
$2,624.40
|
| Rate for Payer: Cigna Commercial |
$8,048.16
|
| Rate for Payer: Health EOS Commercial |
$7,785.72
|
| Rate for Payer: HFN Commercial |
$8,048.16
|
| Rate for Payer: Multiplan Commercial |
$6,998.40
|
| Rate for Payer: NAPHCARE Commercial |
$5,248.80
|
| Rate for Payer: Preferred Network Access Commercial |
$8,048.16
|
| Rate for Payer: Quartz Beloit One Network |
$4,286.52
|
| Rate for Payer: Quartz Commercial |
$5,248.80
|
| Rate for Payer: WEA Trust Commercial |
$4,811.40
|
| Rate for Payer: WPS Commercial |
$6,479.64
|
|
|
Hy-Fiber Supplement
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS B4104
|
| Hospital Charge Code |
3031439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Aetna Managed Medicare |
$1.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.36
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.50
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.90
|
| Rate for Payer: Quartz Medicare Advantage |
$3.60
|
| Rate for Payer: The Alliance Commercial |
$24.00
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
Hy-Fiber Supplement
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS B4104
|
| Hospital Charge Code |
3031439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$5.52 |
| Rate for Payer: Aetna Commercial |
$5.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.18
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.52
|
| Rate for Payer: Health EOS Commercial |
$5.34
|
| Rate for Payer: HFN Commercial |
$5.52
|
| Rate for Payer: Multiplan Commercial |
$4.80
|
| Rate for Payer: NAPHCARE Commercial |
$3.60
|
| Rate for Payer: Preferred Network Access Commercial |
$5.52
|
| Rate for Payer: Quartz Beloit One Network |
$2.94
|
| Rate for Payer: Quartz Commercial |
$3.60
|
| Rate for Payer: WEA Trust Commercial |
$3.30
|
| Rate for Payer: WPS Commercial |
$4.44
|
|
|
HYMEN REPAIR, IMPERFORATE
|
Facility
|
OP
|
$1,084.00
|
|
| Hospital Charge Code |
2960125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$303.52 |
| Max. Negotiated Rate |
$4,336.00 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Aetna Managed Medicare |
$303.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$704.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$542.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$520.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$606.61
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$813.00
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$704.60
|
| Rate for Payer: Quartz Medicare Advantage |
$650.40
|
| Rate for Payer: The Alliance Commercial |
$4,336.00
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
HYMEN REPAIR, IMPERFORATE
|
Facility
|
IP
|
$1,084.00
|
|
| Hospital Charge Code |
2960125
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$531.16 |
| Max. Negotiated Rate |
$997.28 |
| Rate for Payer: Aetna Commercial |
$975.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$932.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$574.52
|
| Rate for Payer: Cash Price |
$325.20
|
| Rate for Payer: Cigna Commercial |
$997.28
|
| Rate for Payer: Health EOS Commercial |
$964.76
|
| Rate for Payer: HFN Commercial |
$997.28
|
| Rate for Payer: Multiplan Commercial |
$867.20
|
| Rate for Payer: NAPHCARE Commercial |
$650.40
|
| Rate for Payer: Preferred Network Access Commercial |
$997.28
|
| Rate for Payer: Quartz Beloit One Network |
$531.16
|
| Rate for Payer: Quartz Commercial |
$650.40
|
| Rate for Payer: WEA Trust Commercial |
$596.20
|
| Rate for Payer: WPS Commercial |
$802.92
|
|
|
Hymovis Charge
|
Professional
|
Both
|
$986.00
|
|
|
Service Code
|
HCPCS J7322
|
| Hospital Charge Code |
5204742
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.26 |
| Max. Negotiated Rate |
$936.70 |
| Rate for Payer: Aetna Commercial |
$936.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$847.96
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cash Price |
$295.80
|
| Rate for Payer: Cigna Commercial |
$936.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.51
|
| Rate for Payer: Health EOS Commercial |
$897.26
|
| Rate for Payer: HFN Commercial |
$936.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.72
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$44.72
|
| Rate for Payer: Multiplan Commercial |
$788.80
|
| Rate for Payer: Preferred Network Access Commercial |
$936.70
|
| Rate for Payer: Quartz Beloit One Network |
$433.84
|
| Rate for Payer: Quartz Commercial |
$562.02
|
| Rate for Payer: The Alliance Commercial |
$493.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.26
|
| Rate for Payer: WEA Trust Commercial |
$542.30
|
| Rate for Payer: WPS Commercial |
$43.77
|
|
