|
Hydrogel Plugs
|
Facility
|
OP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$408.84 |
| Max. Negotiated Rate |
$1,343.35 |
| Rate for Payer: Aetna Commercial |
$1,314.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Aetna Managed Medicare |
$408.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$949.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$730.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$700.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.88
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,343.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$817.13
|
| Rate for Payer: Health EOS Commercial |
$1,299.54
|
| Rate for Payer: HFN Commercial |
$1,343.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,095.12
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: NAPHCARE Commercial |
$876.10
|
| Rate for Payer: Preferred Network Access Commercial |
$1,343.35
|
| Rate for Payer: Quartz Beloit One Network |
$715.48
|
| Rate for Payer: Quartz Commercial |
$949.10
|
| Rate for Payer: Quartz Medicare Advantage |
$876.10
|
| Rate for Payer: The Alliance Commercial |
$730.08
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
Hydrogel Plugs
|
Professional
|
Both
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$642.47 |
| Max. Negotiated Rate |
$1,387.15 |
| Rate for Payer: Aetna Commercial |
$1,387.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,387.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$730.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$876.10
|
| Rate for Payer: Health EOS Commercial |
$1,328.75
|
| Rate for Payer: HFN Commercial |
$1,387.15
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,387.15
|
| Rate for Payer: Quartz Beloit One Network |
$642.47
|
| Rate for Payer: Quartz Commercial |
$832.29
|
| Rate for Payer: The Alliance Commercial |
$730.08
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
Hydrogel Plugs
|
Facility
|
IP
|
$1,404.00
|
|
|
Service Code
|
HCPCS C2613
|
| Hospital Charge Code |
5577489
|
|
Hospital Revenue Code
|
621
|
| Min. Negotiated Rate |
$715.48 |
| Max. Negotiated Rate |
$1,343.35 |
| Rate for Payer: Aetna Commercial |
$1,314.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,255.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$773.88
|
| Rate for Payer: Cash Price |
$421.20
|
| Rate for Payer: Cigna Commercial |
$1,343.35
|
| Rate for Payer: Health EOS Commercial |
$1,299.54
|
| Rate for Payer: HFN Commercial |
$1,343.35
|
| Rate for Payer: Multiplan Commercial |
$1,168.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,343.35
|
| Rate for Payer: Quartz Beloit One Network |
$715.48
|
| Rate for Payer: Quartz Commercial |
$876.10
|
| Rate for Payer: WEA Trust Commercial |
$803.09
|
| Rate for Payer: WPS Commercial |
$1,081.50
|
|
|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
OP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$58.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$156.00
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$124.80
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$124.80
|
| Rate for Payer: The Alliance Commercial |
$104.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
HYDROGEL SOLO SITE 3oz NON-STE
|
Facility
|
IP
|
$200.00
|
|
| Hospital Charge Code |
2963980
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
HYDROGEL STERILE 8gr INTRASITE
|
Facility
|
OP
|
$93.00
|
|
| Hospital Charge Code |
2963182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.08 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Aetna Managed Medicare |
$27.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$48.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.13
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.54
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: NAPHCARE Commercial |
$58.03
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$62.87
|
| Rate for Payer: Quartz Medicare Advantage |
$58.03
|
| Rate for Payer: The Alliance Commercial |
$48.36
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
HYDROGEL STERILE 8gr INTRASITE
|
Facility
|
IP
|
$93.00
|
|
| Hospital Charge Code |
2963182
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$47.39 |
| Max. Negotiated Rate |
$88.98 |
| Rate for Payer: Aetna Commercial |
$87.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$83.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.26
|
| Rate for Payer: Cash Price |
$27.90
|
| Rate for Payer: Cigna Commercial |
$88.98
|
| Rate for Payer: Health EOS Commercial |
$86.08
|
| Rate for Payer: HFN Commercial |
$88.98
|
| Rate for Payer: Multiplan Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$88.98
|
| Rate for Payer: Quartz Beloit One Network |
$47.39
|
| Rate for Payer: Quartz Commercial |
$58.03
|
| Rate for Payer: WEA Trust Commercial |
$53.20
|
| Rate for Payer: WPS Commercial |
$71.64
|
|
|
Hydrogen Peroxide 16oz [Med]
|
Facility
|
IP
|
$6.00
|
|
| Hospital Charge Code |
2974947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Hydrogen Peroxide 16oz [Med]
|
Facility
|
OP
|
$6.00
|
|
| Hospital Charge Code |
2974947
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Hydromorphone Charge
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.54 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.54
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$12.36
|
|
|
Hydromorphone Charge
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.95 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.95
|
| Rate for Payer: Health EOS Commercial |
$23.66
|
| Rate for Payer: HFN Commercial |
$24.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$24.70
|
| Rate for Payer: Quartz Beloit One Network |
$11.44
|
| Rate for Payer: Quartz Commercial |
$14.82
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$12.36
|
|
|
Hydromorphone Charge
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J1170
|
| Hospital Charge Code |
2983558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
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 |
$4.95 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$24.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.95
|
| Rate for Payer: Health EOS Commercial |
$23.66
|
| Rate for Payer: HFN Commercial |
$24.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.15
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$24.70
|
| Rate for Payer: Quartz Beloit One Network |
$11.44
|
| Rate for Payer: Quartz Commercial |
$14.82
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$12.36
|
|
|
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 |
$12.74 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$15.60
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$19.26
|
|
|
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 |
$6.54 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$23.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$22.36
|
| Rate for Payer: Aetna Managed Medicare |
$7.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.78
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.54
|
| Rate for Payer: Health EOS Commercial |
$23.14
|
| Rate for Payer: HFN Commercial |
$23.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.50
|
| Rate for Payer: Multiplan Commercial |
$20.80
|
| Rate for Payer: NAPHCARE Commercial |
$15.60
|
| Rate for Payer: Preferred Network Access Commercial |
$23.92
|
| Rate for Payer: Quartz Beloit One Network |
$12.74
|
| Rate for Payer: Quartz Commercial |
$16.90
|
| Rate for Payer: Quartz Medicare Advantage |
$15.60
|
| Rate for Payer: The Alliance Commercial |
$13.00
|
| Rate for Payer: WEA Trust Commercial |
$14.30
|
| Rate for Payer: WPS Commercial |
$12.36
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.83 |
| Max. Negotiated Rate |
$62.24 |
| Rate for Payer: Aetna Commercial |
$62.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$62.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$32.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.31
|
| Rate for Payer: Health EOS Commercial |
$59.62
|
| Rate for Payer: HFN Commercial |
$62.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.29
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$62.24
|
| Rate for Payer: Quartz Beloit One Network |
$28.83
|
| Rate for Payer: Quartz Commercial |
$37.35
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
Hydroxyprogesterone 10 mg Charge
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS J1726
|
| Hospital Charge Code |
2958915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
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 |
$2.29 |
| Max. Negotiated Rate |
$43.50 |
| Rate for Payer: Aetna Commercial |
$4.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$15.82
|
| Rate for Payer: Anthem Medicare Advantage |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15.82
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.42
|
| Rate for Payer: Health EOS Commercial |
$4.73
|
| Rate for Payer: HFN Commercial |
$4.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.68
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15.82
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$23.73
|
| Rate for Payer: Preferred Network Access Commercial |
$4.94
|
| Rate for Payer: Quartz Beloit One Network |
$2.29
|
| Rate for Payer: Quartz Commercial |
$2.96
|
| Rate for Payer: Quartz Medicare Advantage |
$15.82
|
| Rate for Payer: The Alliance Commercial |
$43.50
|
| Rate for Payer: United Healthcare Medicaid |
$13.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15.82
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$36.06
|
|
|
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 |
$1.46 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Aetna Managed Medicare |
$1.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.08
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3.90
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: NAPHCARE Commercial |
$3.12
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.38
|
| Rate for Payer: Quartz Medicare Advantage |
$3.12
|
| Rate for Payer: The Alliance Commercial |
$63.27
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$36.06
|
|
|
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 |
$2.55 |
| Max. Negotiated Rate |
$4.78 |
| Rate for Payer: Aetna Commercial |
$4.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2.76
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna Commercial |
$4.78
|
| Rate for Payer: Health EOS Commercial |
$4.63
|
| Rate for Payer: HFN Commercial |
$4.78
|
| Rate for Payer: Multiplan Commercial |
$4.16
|
| Rate for Payer: Preferred Network Access Commercial |
$4.78
|
| Rate for Payer: Quartz Beloit One Network |
$2.55
|
| Rate for Payer: Quartz Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$2.86
|
| Rate for Payer: WPS Commercial |
$3.85
|
|
|
HYDRUS MICROSTENT F00022
|
Facility
|
IP
|
$8,748.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6151653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,457.98 |
| Max. Negotiated Rate |
$8,370.09 |
| Rate for Payer: Aetna Commercial |
$8,188.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,824.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,821.90
|
| Rate for Payer: Cash Price |
$2,624.40
|
| Rate for Payer: Cigna Commercial |
$8,370.09
|
| Rate for Payer: Health EOS Commercial |
$8,097.15
|
| Rate for Payer: HFN Commercial |
$8,370.09
|
| Rate for Payer: Multiplan Commercial |
$7,278.34
|
| Rate for Payer: Preferred Network Access Commercial |
$8,370.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,457.98
|
| Rate for Payer: Quartz Commercial |
$5,458.75
|
| Rate for Payer: WEA Trust Commercial |
$5,003.86
|
| Rate for Payer: WPS Commercial |
$6,738.58
|
|
|
HYDRUS MICROSTENT F00022
|
Facility
|
OP
|
$8,748.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
6151653
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,547.42 |
| Max. Negotiated Rate |
$8,370.09 |
| Rate for Payer: Aetna Commercial |
$8,188.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,824.21
|
| Rate for Payer: Aetna Managed Medicare |
$2,547.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,913.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,548.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,367.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,821.90
|
| Rate for Payer: Cash Price |
$2,624.40
|
| Rate for Payer: Cigna Commercial |
$8,370.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,091.34
|
| Rate for Payer: Health EOS Commercial |
$8,097.15
|
| Rate for Payer: HFN Commercial |
$8,370.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,823.44
|
| Rate for Payer: Multiplan Commercial |
$7,278.34
|
| Rate for Payer: NAPHCARE Commercial |
$5,458.75
|
| Rate for Payer: Preferred Network Access Commercial |
$8,370.09
|
| Rate for Payer: Quartz Beloit One Network |
$4,457.98
|
| Rate for Payer: Quartz Commercial |
$5,913.65
|
| Rate for Payer: Quartz Medicare Advantage |
$5,458.75
|
| Rate for Payer: The Alliance Commercial |
$4,548.96
|
| Rate for Payer: WEA Trust Commercial |
$5,003.86
|
| Rate for Payer: WPS Commercial |
$6,738.58
|
|
|
Hy-Fiber Supplement
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS B4104
|
| Hospital Charge Code |
3031439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Aetna Managed Medicare |
$1.75
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.49
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.68
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: NAPHCARE Commercial |
$3.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$4.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3.74
|
| Rate for Payer: The Alliance Commercial |
$3.12
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
|
Hy-Fiber Supplement
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS B4104
|
| Hospital Charge Code |
3031439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$5.74 |
| Rate for Payer: Aetna Commercial |
$5.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.31
|
| Rate for Payer: Cash Price |
$1.80
|
| Rate for Payer: Cigna Commercial |
$5.74
|
| Rate for Payer: Health EOS Commercial |
$5.55
|
| Rate for Payer: HFN Commercial |
$5.74
|
| Rate for Payer: Multiplan Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5.74
|
| Rate for Payer: Quartz Beloit One Network |
$3.06
|
| Rate for Payer: Quartz Commercial |
$3.74
|
| Rate for Payer: WEA Trust Commercial |
$3.43
|
| Rate for Payer: WPS Commercial |
$4.62
|
|
