|
Inj, Clindamycin Phosp 300 mg S0077
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
4506674
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$55.49 |
| Rate for Payer: Aetna Commercial |
$54.29
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$51.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$31.97
|
| Rate for Payer: Cash Price |
$17.40
|
| Rate for Payer: Cigna Commercial |
$55.49
|
| Rate for Payer: Health EOS Commercial |
$53.68
|
| Rate for Payer: HFN Commercial |
$55.49
|
| Rate for Payer: Multiplan Commercial |
$48.26
|
| Rate for Payer: Preferred Network Access Commercial |
$55.49
|
| Rate for Payer: Quartz Beloit One Network |
$29.56
|
| Rate for Payer: Quartz Commercial |
$36.19
|
| Rate for Payer: WEA Trust Commercial |
$33.18
|
| Rate for Payer: WPS Commercial |
$44.68
|
|
|
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 |
$21.48 |
| Max. Negotiated Rate |
$268.74 |
| Rate for Payer: Aetna Commercial |
$268.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$21.48
|
| Rate for Payer: Anthem Medicare Advantage |
$21.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.48
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$268.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.74
|
| Rate for Payer: Health EOS Commercial |
$257.42
|
| Rate for Payer: HFN Commercial |
$268.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.48
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$32.21
|
| Rate for Payer: Preferred Network Access Commercial |
$268.74
|
| Rate for Payer: Quartz Beloit One Network |
$124.47
|
| Rate for Payer: Quartz Commercial |
$161.24
|
| Rate for Payer: Quartz Medicare Advantage |
$21.48
|
| Rate for Payer: The Alliance Commercial |
$59.06
|
| Rate for Payer: United Healthcare Medicaid |
$21.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.48
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$74.34
|
|
|
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 |
$39.34 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Aetna Managed Medicare |
$79.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$183.87
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$141.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$135.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$39.34
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$212.16
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: NAPHCARE Commercial |
$169.73
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$183.87
|
| Rate for Payer: Quartz Medicare Advantage |
$169.73
|
| Rate for Payer: The Alliance Commercial |
$85.90
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$74.34
|
|
|
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 |
$138.61 |
| Max. Negotiated Rate |
$260.25 |
| Rate for Payer: Aetna Commercial |
$254.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$243.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$149.93
|
| Rate for Payer: Cash Price |
$81.60
|
| Rate for Payer: Cigna Commercial |
$260.25
|
| Rate for Payer: Health EOS Commercial |
$251.76
|
| Rate for Payer: HFN Commercial |
$260.25
|
| Rate for Payer: Multiplan Commercial |
$226.30
|
| Rate for Payer: Preferred Network Access Commercial |
$260.25
|
| Rate for Payer: Quartz Beloit One Network |
$138.61
|
| Rate for Payer: Quartz Commercial |
$169.73
|
| Rate for Payer: WEA Trust Commercial |
$155.58
|
| Rate for Payer: WPS Commercial |
$209.52
|
|
|
Inj Cystogram
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$452.52 |
| Max. Negotiated Rate |
$849.64 |
| Rate for Payer: Aetna Commercial |
$831.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$489.47
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$849.64
|
| Rate for Payer: Health EOS Commercial |
$821.93
|
| Rate for Payer: HFN Commercial |
$849.64
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: Preferred Network Access Commercial |
$849.64
|
| Rate for Payer: Quartz Beloit One Network |
$452.52
|
| Rate for Payer: Quartz Commercial |
$554.11
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$684.03
|
|
|
Inj Cystogram
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$25.91 |
| Max. Negotiated Rate |
$877.34 |
| Rate for Payer: Aetna Commercial |
$877.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Aetna Managed Medicare |
$36.49
|
| Rate for Payer: Anthem Medicare Advantage |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.49
|
| 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 |
$877.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.49
|
| Rate for Payer: Health EOS Commercial |
$840.40
|
| Rate for Payer: HFN Commercial |
$877.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$153.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$153.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.49
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: NAPHCARE Commercial |
$54.74
|
| Rate for Payer: Preferred Network Access Commercial |
$877.34
|
| Rate for Payer: Quartz Beloit One Network |
$406.35
|
| Rate for Payer: Quartz Commercial |
$526.41
|
| Rate for Payer: Quartz Medicare Advantage |
$36.49
|
| Rate for Payer: The Alliance Commercial |
$155.10
|
| Rate for Payer: United Healthcare Medicaid |
$25.91
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.49
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$164.22
|
|
|
Inj Cystogram
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
3072744
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$145.97 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$831.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$794.23
|
| Rate for Payer: Aetna Managed Medicare |
$258.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$600.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$461.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$443.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$489.47
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cash Price |
$266.40
|
| Rate for Payer: Cigna Commercial |
$849.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Health EOS Commercial |
$821.93
|
| Rate for Payer: HFN Commercial |
$849.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$692.64
|
| Rate for Payer: Multiplan Commercial |
$738.82
|
| Rate for Payer: NAPHCARE Commercial |
$554.11
|
| Rate for Payer: Preferred Network Access Commercial |
$849.64
|
| Rate for Payer: Quartz Beloit One Network |
$452.52
|
| Rate for Payer: Quartz Commercial |
$600.29
|
| Rate for Payer: Quartz Medicare Advantage |
$554.11
|
| Rate for Payer: The Alliance Commercial |
$145.97
|
| Rate for Payer: WEA Trust Commercial |
$507.94
|
| Rate for Payer: WPS Commercial |
$684.03
|
|
|
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 |
$2,477.32 |
| Max. Negotiated Rate |
$4,651.29 |
| Rate for Payer: Aetna Commercial |
$4,550.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,347.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,679.55
|
| Rate for Payer: Cash Price |
$1,458.39
|
| Rate for Payer: Cigna Commercial |
$4,651.29
|
| Rate for Payer: Health EOS Commercial |
$4,499.62
|
| Rate for Payer: HFN Commercial |
$4,651.29
|
| Rate for Payer: Multiplan Commercial |
$4,044.60
|
| Rate for Payer: Preferred Network Access Commercial |
$4,651.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,477.32
|
| Rate for Payer: Quartz Commercial |
$3,033.45
|
| Rate for Payer: WEA Trust Commercial |
$2,780.66
|
| Rate for Payer: WPS Commercial |
$3,744.66
|
|
|
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 |
$1,415.61 |
| Max. Negotiated Rate |
$4,651.29 |
| Rate for Payer: Aetna Commercial |
$4,550.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,347.95
|
| Rate for Payer: Aetna Managed Medicare |
$1,415.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,286.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,527.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,426.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,679.55
|
| Rate for Payer: Cash Price |
$1,458.39
|
| Rate for Payer: Cigna Commercial |
$4,651.29
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,829.28
|
| Rate for Payer: Health EOS Commercial |
$4,499.62
|
| Rate for Payer: HFN Commercial |
$4,651.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,791.81
|
| Rate for Payer: Multiplan Commercial |
$4,044.60
|
| Rate for Payer: NAPHCARE Commercial |
$3,033.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,651.29
|
| Rate for Payer: Quartz Beloit One Network |
$2,477.32
|
| Rate for Payer: Quartz Commercial |
$3,286.24
|
| Rate for Payer: Quartz Medicare Advantage |
$3,033.45
|
| Rate for Payer: The Alliance Commercial |
$2,527.88
|
| Rate for Payer: WEA Trust Commercial |
$2,780.66
|
| Rate for Payer: WPS Commercial |
$3,744.66
|
|
|
INJECTABLE KIT AUGMENT SYNTHETIC K30003010
|
Facility
|
IP
|
$19,044.00
|
|
|
Service Code
|
HCPCS C1763
|
| Hospital Charge Code |
6177956
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,704.82 |
| Max. Negotiated Rate |
$18,221.30 |
| Rate for Payer: Aetna Commercial |
$17,825.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,032.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,497.05
|
| Rate for Payer: Cash Price |
$5,713.20
|
| Rate for Payer: Cigna Commercial |
$18,221.30
|
| Rate for Payer: Health EOS Commercial |
$17,627.13
|
| Rate for Payer: HFN Commercial |
$18,221.30
|
| Rate for Payer: Multiplan Commercial |
$15,844.61
|
| Rate for Payer: Preferred Network Access Commercial |
$18,221.30
|
| Rate for Payer: Quartz Beloit One Network |
$9,704.82
|
| Rate for Payer: Quartz Commercial |
$11,883.46
|
| Rate for Payer: WEA Trust Commercial |
$10,893.17
|
| Rate for Payer: WPS Commercial |
$14,669.59
|
|
|
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 |
$5,545.61 |
| Max. Negotiated Rate |
$18,221.30 |
| Rate for Payer: Aetna Commercial |
$17,825.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,032.95
|
| Rate for Payer: Aetna Managed Medicare |
$5,545.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12,873.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,902.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9,506.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,497.05
|
| Rate for Payer: Cash Price |
$5,713.20
|
| Rate for Payer: Cigna Commercial |
$18,221.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,083.61
|
| Rate for Payer: Health EOS Commercial |
$17,627.13
|
| Rate for Payer: HFN Commercial |
$18,221.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,854.32
|
| Rate for Payer: Multiplan Commercial |
$15,844.61
|
| Rate for Payer: NAPHCARE Commercial |
$11,883.46
|
| Rate for Payer: Preferred Network Access Commercial |
$18,221.30
|
| Rate for Payer: Quartz Beloit One Network |
$9,704.82
|
| Rate for Payer: Quartz Commercial |
$12,873.74
|
| Rate for Payer: Quartz Medicare Advantage |
$11,883.46
|
| Rate for Payer: The Alliance Commercial |
$9,902.88
|
| Rate for Payer: WEA Trust Commercial |
$10,893.17
|
| Rate for Payer: WPS Commercial |
$14,669.59
|
|
|
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG 64454
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
CPT 64454
|
| Hospital Charge Code |
5707693
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$889.20 |
| Rate for Payer: Aetna Commercial |
$889.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$804.96
|
| Rate for Payer: Aetna Managed Medicare |
$72.10
|
| Rate for Payer: Anthem Medicare Advantage |
$72.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$72.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$72.10
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$889.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$171.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.10
|
| Rate for Payer: Health EOS Commercial |
$851.76
|
| Rate for Payer: HFN Commercial |
$889.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$286.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$286.06
|
| Rate for Payer: Independent Care Health Plan Medicare |
$72.10
|
| Rate for Payer: Multiplan Commercial |
$748.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.15
|
| Rate for Payer: Preferred Network Access Commercial |
$889.20
|
| Rate for Payer: Quartz Beloit One Network |
$411.84
|
| Rate for Payer: Quartz Commercial |
$533.52
|
| Rate for Payer: Quartz Medicare Advantage |
$72.10
|
| Rate for Payer: The Alliance Commercial |
$306.44
|
| Rate for Payer: United Healthcare Medicaid |
$171.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$72.10
|
| Rate for Payer: WEA Trust Commercial |
$514.80
|
| Rate for Payer: WPS Commercial |
$324.46
|
|
|
Injection, Bupivicaine Hydro S0020
|
Professional
|
Both
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.37
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.92
|
| Rate for Payer: Quartz Beloit One Network |
$3.20
|
| Rate for Payer: Quartz Commercial |
$4.15
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Injection, Bupivicaine Hydro S0020
|
Facility
|
IP
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.37
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
Injection, Bupivicaine Hydro S0020
|
Facility
|
OP
|
$7.00
|
|
| Hospital Charge Code |
4392900
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$6.70 |
| Rate for Payer: Aetna Commercial |
$6.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$2.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.73
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.07
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.46
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$4.37
|
| Rate for Payer: Preferred Network Access Commercial |
$6.70
|
| Rate for Payer: Quartz Beloit One Network |
$3.57
|
| Rate for Payer: Quartz Commercial |
$4.73
|
| Rate for Payer: Quartz Medicare Advantage |
$4.37
|
| Rate for Payer: The Alliance Commercial |
$3.64
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$5.39
|
|
|
INJECTION CANNULA TFNA -S TRAUMACEM V+ 03.702.121S
|
Facility
|
IP
|
$4,388.68
|
|
| Hospital Charge Code |
6246252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,236.47 |
| Max. Negotiated Rate |
$4,199.09 |
| Rate for Payer: Aetna Commercial |
$4,107.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,925.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,419.04
|
| Rate for Payer: Cash Price |
$1,316.60
|
| Rate for Payer: Cigna Commercial |
$4,199.09
|
| Rate for Payer: Health EOS Commercial |
$4,062.16
|
| Rate for Payer: HFN Commercial |
$4,199.09
|
| Rate for Payer: Multiplan Commercial |
$3,651.38
|
| Rate for Payer: Preferred Network Access Commercial |
$4,199.09
|
| Rate for Payer: Quartz Beloit One Network |
$2,236.47
|
| Rate for Payer: Quartz Commercial |
$2,738.54
|
| Rate for Payer: WEA Trust Commercial |
$2,510.32
|
| Rate for Payer: WPS Commercial |
$3,380.60
|
|
|
INJECTION CANNULA TFNA -S TRAUMACEM V+ 03.702.121S
|
Facility
|
OP
|
$4,388.68
|
|
| Hospital Charge Code |
6246252
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,277.98 |
| Max. Negotiated Rate |
$4,199.09 |
| Rate for Payer: Aetna Commercial |
$4,107.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,925.24
|
| Rate for Payer: Aetna Managed Medicare |
$1,277.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,966.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,282.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,190.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,419.04
|
| Rate for Payer: Cash Price |
$1,316.60
|
| Rate for Payer: Cigna Commercial |
$4,199.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,554.21
|
| Rate for Payer: Health EOS Commercial |
$4,062.16
|
| Rate for Payer: HFN Commercial |
$4,199.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,423.17
|
| Rate for Payer: Multiplan Commercial |
$3,651.38
|
| Rate for Payer: NAPHCARE Commercial |
$2,738.54
|
| Rate for Payer: Preferred Network Access Commercial |
$4,199.09
|
| Rate for Payer: Quartz Beloit One Network |
$2,236.47
|
| Rate for Payer: Quartz Commercial |
$2,966.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,738.54
|
| Rate for Payer: The Alliance Commercial |
$2,282.11
|
| Rate for Payer: WEA Trust Commercial |
$2,510.32
|
| Rate for Payer: WPS Commercial |
$3,380.60
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Facility
|
IP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,912.53 |
| Max. Negotiated Rate |
$3,590.87 |
| Rate for Payer: Aetna Commercial |
$3,512.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,356.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,068.65
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,590.87
|
| Rate for Payer: Health EOS Commercial |
$3,473.78
|
| Rate for Payer: HFN Commercial |
$3,590.87
|
| Rate for Payer: Multiplan Commercial |
$3,122.50
|
| Rate for Payer: Preferred Network Access Commercial |
$3,590.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,912.53
|
| Rate for Payer: Quartz Commercial |
$2,341.87
|
| Rate for Payer: WEA Trust Commercial |
$2,146.72
|
| Rate for Payer: WPS Commercial |
$2,890.94
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Professional
|
Both
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$3,707.96 |
| Rate for Payer: Aetna Commercial |
$3,707.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,356.68
|
| Rate for Payer: Aetna Managed Medicare |
$4.02
|
| Rate for Payer: Anthem Medicare Advantage |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.02
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,707.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.81
|
| Rate for Payer: Health EOS Commercial |
$3,551.84
|
| Rate for Payer: HFN Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12.27
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.27
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$3,122.50
|
| Rate for Payer: NAPHCARE Commercial |
$6.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,707.96
|
| Rate for Payer: Quartz Beloit One Network |
$1,717.37
|
| Rate for Payer: Quartz Commercial |
$2,224.78
|
| Rate for Payer: Quartz Medicare Advantage |
$4.02
|
| Rate for Payer: The Alliance Commercial |
$11.07
|
| Rate for Payer: United Healthcare Medicaid |
$4.02
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.02
|
| Rate for Payer: WEA Trust Commercial |
$2,146.72
|
| Rate for Payer: WPS Commercial |
$12.02
|
|
|
Injection, Certolizumab Pegol, 1MG J0717
|
Facility
|
OP
|
$3,753.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
4036657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$3,590.87 |
| Rate for Payer: Aetna Commercial |
$3,512.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,356.68
|
| Rate for Payer: Aetna Managed Medicare |
$4.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,537.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,951.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,873.50
|
| Rate for Payer: Anthem Medicare Advantage |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,068.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.02
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cash Price |
$1,125.90
|
| Rate for Payer: Cigna Commercial |
$3,590.87
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.02
|
| Rate for Payer: Health EOS Commercial |
$3,473.78
|
| Rate for Payer: HFN Commercial |
$3,590.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.02
|
| Rate for Payer: Multiplan Commercial |
$3,122.50
|
| Rate for Payer: NAPHCARE Commercial |
$6.04
|
| Rate for Payer: Preferred Network Access Commercial |
$3,590.87
|
| Rate for Payer: Quartz Beloit One Network |
$1,912.53
|
| Rate for Payer: Quartz Commercial |
$2,537.03
|
| Rate for Payer: Quartz Medicare Advantage |
$4.02
|
| Rate for Payer: The Alliance Commercial |
$16.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.02
|
| Rate for Payer: WEA Trust Commercial |
$2,146.72
|
| Rate for Payer: Wellcare Medicare |
$4.02
|
| Rate for Payer: WPS Commercial |
$12.02
|
|
|
Injection, Denosumab, 1mg J0897
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.03 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$34.32
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$42.37
|
|
|
Injection, Denosumab, 1mg J0897
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.20 |
| Max. Negotiated Rate |
$122.55 |
| Rate for Payer: Aetna Commercial |
$51.48
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$30.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$26.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.20
|
| Rate for Payer: Anthem Medicare Advantage |
$30.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$30.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.64
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$30.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$30.64
|
| Rate for Payer: Health EOS Commercial |
$50.91
|
| Rate for Payer: HFN Commercial |
$52.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.64
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.64
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$30.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$30.64
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$45.96
|
| Rate for Payer: Preferred Network Access Commercial |
$52.62
|
| Rate for Payer: Quartz Beloit One Network |
$28.03
|
| Rate for Payer: Quartz Commercial |
$37.18
|
| Rate for Payer: Quartz Medicare Advantage |
$30.64
|
| Rate for Payer: The Alliance Commercial |
$122.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.64
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: Wellcare Medicare |
$30.64
|
| Rate for Payer: WPS Commercial |
$65.49
|
|
|
Injection, Denosumab, 1mg J0897
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS J0897
|
| Hospital Charge Code |
3451580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.17 |
| Max. Negotiated Rate |
$84.26 |
| Rate for Payer: Aetna Commercial |
$54.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$49.19
|
| Rate for Payer: Aetna Managed Medicare |
$30.64
|
| Rate for Payer: Anthem Medicare Advantage |
$30.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$30.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$30.64
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cash Price |
$16.50
|
| Rate for Payer: Cigna Commercial |
$54.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$26.20
|
| Rate for Payer: Health EOS Commercial |
$52.05
|
| Rate for Payer: HFN Commercial |
$54.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$30.64
|
| Rate for Payer: Multiplan Commercial |
$45.76
|
| Rate for Payer: NAPHCARE Commercial |
$45.96
|
| Rate for Payer: Preferred Network Access Commercial |
$54.34
|
| Rate for Payer: Quartz Beloit One Network |
$25.17
|
| Rate for Payer: Quartz Commercial |
$32.60
|
| Rate for Payer: Quartz Medicare Advantage |
$30.64
|
| Rate for Payer: The Alliance Commercial |
$84.26
|
| Rate for Payer: United Healthcare Medicaid |
$30.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$30.64
|
| Rate for Payer: WEA Trust Commercial |
$31.46
|
| Rate for Payer: WPS Commercial |
$65.49
|
|
|
Injection epidural blood/clot patch 62273
|
Professional
|
Both
|
$1,351.00
|
|
|
Service Code
|
CPT 62273
|
| Hospital Charge Code |
5308646
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$100.15 |
| Max. Negotiated Rate |
$1,334.79 |
| Rate for Payer: Aetna Commercial |
$1,334.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,208.33
|
| Rate for Payer: Aetna Managed Medicare |
$100.15
|
| Rate for Payer: Anthem Medicare Advantage |
$100.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$100.15
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$100.15
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cash Price |
$405.30
|
| Rate for Payer: Cigna Commercial |
$1,334.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$100.15
|
| Rate for Payer: Health EOS Commercial |
$1,278.59
|
| Rate for Payer: HFN Commercial |
$1,334.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$396.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$396.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$100.15
|
| Rate for Payer: Multiplan Commercial |
$1,124.03
|
| Rate for Payer: NAPHCARE Commercial |
$150.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,334.79
|
| Rate for Payer: Quartz Beloit One Network |
$618.22
|
| Rate for Payer: Quartz Commercial |
$800.87
|
| Rate for Payer: Quartz Medicare Advantage |
$100.15
|
| Rate for Payer: The Alliance Commercial |
$425.65
|
| Rate for Payer: United Healthcare Medicaid |
$125.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$100.15
|
| Rate for Payer: WEA Trust Commercial |
$772.77
|
| Rate for Payer: WPS Commercial |
$450.68
|
|
|
Injection Eye Drug 6702850
|
Professional
|
Both
|
$1,396.00
|
|
|
Service Code
|
CPT 67028 50
|
| Hospital Charge Code |
3153484
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$177.55 |
| Max. Negotiated Rate |
$1,379.25 |
| Rate for Payer: Aetna Commercial |
$1,379.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,248.58
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cash Price |
$418.80
|
| Rate for Payer: Cigna Commercial |
$1,379.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$177.55
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$871.10
|
| Rate for Payer: Health EOS Commercial |
$1,321.17
|
| Rate for Payer: HFN Commercial |
$1,379.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$322.59
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$322.59
|
| Rate for Payer: Multiplan Commercial |
$1,161.47
|
| Rate for Payer: Preferred Network Access Commercial |
$1,379.25
|
| Rate for Payer: Quartz Beloit One Network |
$638.81
|
| Rate for Payer: Quartz Commercial |
$827.55
|
| Rate for Payer: The Alliance Commercial |
$725.92
|
| Rate for Payer: United Healthcare Medicaid |
$177.55
|
| Rate for Payer: WEA Trust Commercial |
$798.51
|
| Rate for Payer: WPS Commercial |
$1,075.34
|
|
