|
Inj Admin Non-hormonal Antineoplastic 96401 - Admin Chemo SubQ/IM Non-hormonal Antineoplastic
|
Facility
|
IP
|
$441.00
|
|
|
Service Code
|
CPT 96401
|
| Hospital Charge Code |
3437512
|
|
Hospital Revenue Code
|
331
|
| Min. Negotiated Rate |
$216.09 |
| Max. Negotiated Rate |
$405.72 |
| Rate for Payer: Aetna Commercial |
$396.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$379.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$233.73
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$405.72
|
| Rate for Payer: Health EOS Commercial |
$392.49
|
| Rate for Payer: HFN Commercial |
$405.72
|
| Rate for Payer: Multiplan Commercial |
$352.80
|
| Rate for Payer: NAPHCARE Commercial |
$264.60
|
| Rate for Payer: Preferred Network Access Commercial |
$405.72
|
| Rate for Payer: Quartz Beloit One Network |
$216.09
|
| Rate for Payer: Quartz Commercial |
$264.60
|
| Rate for Payer: WEA Trust Commercial |
$242.55
|
| Rate for Payer: WPS Commercial |
$326.65
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$69.63 |
| Max. Negotiated Rate |
$278.52 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Aetna Managed Medicare |
$69.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$144.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.04
|
| Rate for Payer: Anthem Medicare Advantage |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$69.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$69.63
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$69.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$124.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$69.63
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$259.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$69.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$69.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$69.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$69.63
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$104.44
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$144.95
|
| Rate for Payer: Quartz Medicare Advantage |
$69.63
|
| Rate for Payer: The Alliance Commercial |
$278.52
|
| Rate for Payer: United Healthcare Medicare Advantage |
$69.63
|
| Rate for Payer: United Healthcare PPO |
$167.25
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: Wellcare Medicare |
$69.63
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$109.27 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna Commercial |
$200.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.19
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$205.16
|
| Rate for Payer: Health EOS Commercial |
$198.47
|
| Rate for Payer: HFN Commercial |
$205.16
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: NAPHCARE Commercial |
$133.80
|
| Rate for Payer: Preferred Network Access Commercial |
$205.16
|
| Rate for Payer: Quartz Beloit One Network |
$109.27
|
| Rate for Payer: Quartz Commercial |
$133.80
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Inj Admin SubQ/IM 96372 - Admin Injection Charge
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
2480800
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$211.85 |
| Rate for Payer: Aetna Commercial |
$211.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$191.78
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cash Price |
$66.90
|
| Rate for Payer: Cigna Commercial |
$211.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$133.80
|
| Rate for Payer: Health EOS Commercial |
$202.93
|
| Rate for Payer: HFN Commercial |
$211.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$48.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$48.01
|
| Rate for Payer: Multiplan Commercial |
$178.40
|
| Rate for Payer: Preferred Network Access Commercial |
$211.85
|
| Rate for Payer: Quartz Beloit One Network |
$98.12
|
| Rate for Payer: Quartz Commercial |
$127.11
|
| Rate for Payer: The Alliance Commercial |
$111.50
|
| Rate for Payer: United Healthcare Medicaid |
$3.31
|
| Rate for Payer: WEA Trust Commercial |
$122.65
|
| Rate for Payer: WPS Commercial |
$165.18
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Facility
|
IP
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
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
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Facility
|
OP
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$20.00 |
| 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 |
$1.07
|
| 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 |
$2.03
|
|
|
Inj, Adrenalin, Epinephrine, 0.1 Mg J0171
|
Professional
|
Both
|
$5.00
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
4062103
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$4.75 |
| 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 |
$0.75
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.81
|
| Rate for Payer: Health EOS Commercial |
$4.55
|
| Rate for Payer: HFN Commercial |
$4.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.23
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.23
|
| 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 |
$0.75
|
| Rate for Payer: WEA Trust Commercial |
$2.75
|
| Rate for Payer: WPS Commercial |
$2.03
|
|
|
Inj Ankle Arthrograpy
|
Facility
|
OP
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$252.56 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$811.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$775.72
|
| Rate for Payer: Aetna Managed Medicare |
$252.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$586.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$451.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$432.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$478.06
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$829.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$802.78
|
| Rate for Payer: HFN Commercial |
$829.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$676.50
|
| Rate for Payer: Multiplan Commercial |
$721.60
|
| Rate for Payer: NAPHCARE Commercial |
$541.20
|
| Rate for Payer: Preferred Network Access Commercial |
$829.84
|
| Rate for Payer: Quartz Beloit One Network |
$441.98
|
| Rate for Payer: Quartz Commercial |
$586.30
|
| Rate for Payer: Quartz Medicare Advantage |
$541.20
|
| Rate for Payer: The Alliance Commercial |
$3,608.00
|
| Rate for Payer: WEA Trust Commercial |
$496.10
|
| Rate for Payer: WPS Commercial |
$668.11
|
|
|
Inj Ankle Arthrograpy
|
Professional
|
Both
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$45.18 |
| Max. Negotiated Rate |
$856.90 |
| Rate for Payer: Aetna Commercial |
$856.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$775.72
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$856.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$45.18
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$541.20
|
| Rate for Payer: Health EOS Commercial |
$820.82
|
| Rate for Payer: HFN Commercial |
$856.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$173.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$173.25
|
| Rate for Payer: Multiplan Commercial |
$721.60
|
| Rate for Payer: Preferred Network Access Commercial |
$856.90
|
| Rate for Payer: Quartz Beloit One Network |
$396.88
|
| Rate for Payer: Quartz Commercial |
$514.14
|
| Rate for Payer: The Alliance Commercial |
$451.00
|
| Rate for Payer: United Healthcare Medicaid |
$45.18
|
| Rate for Payer: WEA Trust Commercial |
$496.10
|
| Rate for Payer: WPS Commercial |
$668.11
|
|
|
Inj Ankle Arthrograpy
|
Facility
|
IP
|
$902.00
|
|
|
Service Code
|
CPT 27648
|
| Hospital Charge Code |
3072737
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$441.98 |
| Max. Negotiated Rate |
$829.84 |
| Rate for Payer: Aetna Commercial |
$811.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$775.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$478.06
|
| Rate for Payer: Cash Price |
$270.60
|
| Rate for Payer: Cigna Commercial |
$829.84
|
| Rate for Payer: Health EOS Commercial |
$802.78
|
| Rate for Payer: HFN Commercial |
$829.84
|
| Rate for Payer: Multiplan Commercial |
$721.60
|
| Rate for Payer: NAPHCARE Commercial |
$541.20
|
| Rate for Payer: Preferred Network Access Commercial |
$829.84
|
| Rate for Payer: Quartz Beloit One Network |
$441.98
|
| Rate for Payer: Quartz Commercial |
$541.20
|
| Rate for Payer: WEA Trust Commercial |
$496.10
|
| Rate for Payer: WPS Commercial |
$668.11
|
|
|
Inj, Bupivacaine Liposome C9290
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3.92
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Inj, Bupivacaine Liposome C9290
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$6.44 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.20
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Inj, Bupivacaine Liposome C9290
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS C9290
|
| Hospital Charge Code |
4157332
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$6.65 |
| Rate for Payer: Aetna Commercial |
$6.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.20
|
| Rate for Payer: Health EOS Commercial |
$6.37
|
| Rate for Payer: HFN Commercial |
$6.65
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: Preferred Network Access Commercial |
$6.65
|
| Rate for Payer: Quartz Beloit One Network |
$3.08
|
| Rate for Payer: Quartz Commercial |
$3.99
|
| Rate for Payer: The Alliance Commercial |
$3.50
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$5.18
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Facility
|
OP
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.24 |
| Max. Negotiated Rate |
$232.00 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Aetna Managed Medicare |
$16.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.46
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$43.50
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$34.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$37.70
|
| Rate for Payer: Quartz Medicare Advantage |
$34.80
|
| Rate for Payer: The Alliance Commercial |
$232.00
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Professional
|
Both
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$55.10 |
| Rate for Payer: Aetna Commercial |
$55.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$29.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.80
|
| Rate for Payer: Health EOS Commercial |
$52.78
|
| Rate for Payer: HFN Commercial |
$55.10
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: Preferred Network Access Commercial |
$55.10
|
| Rate for Payer: Quartz Beloit One Network |
$25.52
|
| Rate for Payer: Quartz Commercial |
$33.06
|
| Rate for Payer: The Alliance Commercial |
$29.00
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
Inj, Clindamycin Phosp 300 mg S0077
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.42 |
| Max. Negotiated Rate |
$53.36 |
| Rate for Payer: Aetna Commercial |
$52.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.74
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$53.36
|
| Rate for Payer: Health EOS Commercial |
$51.62
|
| Rate for Payer: HFN Commercial |
$53.36
|
| Rate for Payer: Multiplan Commercial |
$46.40
|
| Rate for Payer: NAPHCARE Commercial |
$34.80
|
| Rate for Payer: Preferred Network Access Commercial |
$53.36
|
| Rate for Payer: Quartz Beloit One Network |
$28.42
|
| Rate for Payer: Quartz Commercial |
$34.80
|
| Rate for Payer: WEA Trust Commercial |
$31.90
|
| Rate for Payer: WPS Commercial |
$42.96
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Facility
|
IP
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$133.28 |
| Max. Negotiated Rate |
$250.24 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$163.20
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$201.47
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Facility
|
OP
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$1,088.00 |
| Rate for Payer: Aetna Commercial |
$244.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Aetna Managed Medicare |
$76.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$176.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$136.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$130.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$144.16
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$250.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.83
|
| Rate for Payer: Health EOS Commercial |
$242.08
|
| Rate for Payer: HFN Commercial |
$250.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$204.00
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: NAPHCARE Commercial |
$163.20
|
| Rate for Payer: Preferred Network Access Commercial |
$250.24
|
| Rate for Payer: Quartz Beloit One Network |
$133.28
|
| Rate for Payer: Quartz Commercial |
$176.80
|
| Rate for Payer: Quartz Medicare Advantage |
$163.20
|
| Rate for Payer: The Alliance Commercial |
$1,088.00
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$71.48
|
|
|
Inj Cosyntropin (Cortrosyn) 0.25 MG J0834
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
3908783
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.11 |
| Max. Negotiated Rate |
$258.40 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$233.92
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.59
|
| Rate for Payer: Health EOS Commercial |
$247.52
|
| Rate for Payer: HFN Commercial |
$258.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.15
|
| Rate for Payer: Multiplan Commercial |
$217.60
|
| Rate for Payer: Preferred Network Access Commercial |
$258.40
|
| Rate for Payer: Quartz Beloit One Network |
$119.68
|
| Rate for Payer: Quartz Commercial |
$155.04
|
| Rate for Payer: The Alliance Commercial |
$136.00
|
| Rate for Payer: United Healthcare Medicaid |
$27.11
|
| Rate for Payer: WEA Trust Commercial |
$149.60
|
| Rate for Payer: WPS Commercial |
$71.48
|
|
|
Inj Cystogram
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$248.64 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Aetna Managed Medicare |
$248.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$577.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$444.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$426.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.00
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$577.20
|
| Rate for Payer: Quartz Medicare Advantage |
$532.80
|
| Rate for Payer: The Alliance Commercial |
$3,552.00
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
Inj Cystogram
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$24.91 |
| Max. Negotiated Rate |
$843.60 |
| Rate for Payer: Aetna Commercial |
$843.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$843.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$532.80
|
| Rate for Payer: Health EOS Commercial |
$808.08
|
| Rate for Payer: HFN Commercial |
$843.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$147.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$147.62
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: Preferred Network Access Commercial |
$843.60
|
| Rate for Payer: Quartz Beloit One Network |
$390.72
|
| Rate for Payer: Quartz Commercial |
$506.16
|
| Rate for Payer: The Alliance Commercial |
$444.00
|
| Rate for Payer: United Healthcare Medicaid |
$24.91
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
Inj Cystogram
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$435.12 |
| Max. Negotiated Rate |
$816.96 |
| Rate for Payer: Aetna Commercial |
$799.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$763.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$470.64
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$816.96
|
| Rate for Payer: Health EOS Commercial |
$790.32
|
| Rate for Payer: HFN Commercial |
$816.96
|
| Rate for Payer: Multiplan Commercial |
$710.40
|
| Rate for Payer: NAPHCARE Commercial |
$532.80
|
| Rate for Payer: Preferred Network Access Commercial |
$816.96
|
| Rate for Payer: Quartz Beloit One Network |
$435.12
|
| Rate for Payer: Quartz Commercial |
$532.80
|
| Rate for Payer: WEA Trust Commercial |
$488.40
|
| Rate for Payer: WPS Commercial |
$657.74
|
|
|
INJECTABLE CEMENT -S TRAUMACEM (TM) V+ 07.702.040S
|
Facility
|
OP
|
$4,861.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246251
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,361.16 |
| Max. Negotiated Rate |
$19,445.20 |
| Rate for Payer: Aetna Commercial |
$4,375.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,180.72
|
| Rate for Payer: Aetna Managed Medicare |
$1,361.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,159.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,430.65
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,333.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,576.49
|
| Rate for Payer: Cash Price |
$1,458.39
|
| Rate for Payer: Cigna Commercial |
$4,472.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,720.38
|
| Rate for Payer: Health EOS Commercial |
$4,326.56
|
| Rate for Payer: HFN Commercial |
$4,472.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,645.98
|
| Rate for Payer: Multiplan Commercial |
$3,889.04
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,472.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,382.04
|
| Rate for Payer: Quartz Commercial |
$3,159.84
|
| Rate for Payer: Quartz Medicare Advantage |
$2,916.78
|
| Rate for Payer: The Alliance Commercial |
$19,445.20
|
| Rate for Payer: WEA Trust Commercial |
$2,673.72
|
| Rate for Payer: WPS Commercial |
$3,600.76
|
|
|
INJECTABLE CEMENT -S TRAUMACEM (TM) V+ 07.702.040S
|
Facility
|
IP
|
$4,861.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
6246251
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,382.04 |
| Max. Negotiated Rate |
$4,472.40 |
| Rate for Payer: Aetna Commercial |
$4,375.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,180.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,576.49
|
| Rate for Payer: Cash Price |
$1,458.39
|
| Rate for Payer: Cigna Commercial |
$4,472.40
|
| Rate for Payer: Health EOS Commercial |
$4,326.56
|
| Rate for Payer: HFN Commercial |
$4,472.40
|
| Rate for Payer: Multiplan Commercial |
$3,889.04
|
| Rate for Payer: NAPHCARE Commercial |
$2,916.78
|
| Rate for Payer: Preferred Network Access Commercial |
$4,472.40
|
| Rate for Payer: Quartz Beloit One Network |
$2,382.04
|
| Rate for Payer: Quartz Commercial |
$2,916.78
|
| Rate for Payer: WEA Trust Commercial |
$2,673.72
|
| Rate for Payer: WPS Commercial |
$3,600.76
|
|
|
INJECTABLE KIT AUGMENT SYNTHETIC K30003010
|
Facility
|
OP
|
$19,044.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
6177956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,332.32 |
| Max. Negotiated Rate |
$76,176.00 |
| Rate for Payer: Aetna Commercial |
$17,139.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,377.84
|
| Rate for Payer: Aetna Managed Medicare |
$5,332.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,378.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,522.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,141.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,093.32
|
| Rate for Payer: Cash Price |
$5,713.20
|
| Rate for Payer: Cigna Commercial |
$17,520.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,657.02
|
| Rate for Payer: Health EOS Commercial |
$16,949.16
|
| Rate for Payer: HFN Commercial |
$17,520.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,283.00
|
| Rate for Payer: Multiplan Commercial |
$15,235.20
|
| Rate for Payer: NAPHCARE Commercial |
$11,426.40
|
| Rate for Payer: Preferred Network Access Commercial |
$17,520.48
|
| Rate for Payer: Quartz Beloit One Network |
$9,331.56
|
| Rate for Payer: Quartz Commercial |
$12,378.60
|
| Rate for Payer: Quartz Medicare Advantage |
$11,426.40
|
| Rate for Payer: The Alliance Commercial |
$76,176.00
|
| Rate for Payer: WEA Trust Commercial |
$10,474.20
|
| Rate for Payer: WPS Commercial |
$14,105.89
|
|
