|
Inj, Medroxyprogesterone Acetate, 1 MG J1050
|
Professional
|
Both
|
$2.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
3397519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.20
|
| Rate for Payer: Health EOS Commercial |
$1.82
|
| Rate for Payer: HFN Commercial |
$1.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1.90
|
| Rate for Payer: Quartz Beloit One Network |
$0.88
|
| Rate for Payer: Quartz Commercial |
$1.14
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.57
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Inj, Medroxyprogesterone Acetate, 1 MG J1050
|
Facility
|
OP
|
$2.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
3397519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Aetna Managed Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.12
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.50
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1.20
|
| Rate for Payer: The Alliance Commercial |
$8.00
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Inj, Medroxyprogesterone Acetate, 1 MG J1050
|
Facility
|
IP
|
$2.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
3397519
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1.06
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna Commercial |
$1.84
|
| Rate for Payer: Health EOS Commercial |
$1.78
|
| Rate for Payer: HFN Commercial |
$1.84
|
| Rate for Payer: Multiplan Commercial |
$1.60
|
| Rate for Payer: NAPHCARE Commercial |
$1.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1.84
|
| Rate for Payer: Quartz Beloit One Network |
$0.98
|
| Rate for Payer: Quartz Commercial |
$1.20
|
| Rate for Payer: WEA Trust Commercial |
$1.10
|
| Rate for Payer: WPS Commercial |
$1.48
|
|
|
Inj Myleogram
|
Facility
|
OP
|
$1,743.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
3072746
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$488.04 |
| Max. Negotiated Rate |
$6,972.00 |
| Rate for Payer: Aetna Commercial |
$1,568.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,498.98
|
| Rate for Payer: Aetna Managed Medicare |
$488.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,132.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$871.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$836.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$923.79
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cigna Commercial |
$1,603.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$1,551.27
|
| Rate for Payer: HFN Commercial |
$1,603.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,307.25
|
| Rate for Payer: Multiplan Commercial |
$1,394.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,045.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,603.56
|
| Rate for Payer: Quartz Beloit One Network |
$854.07
|
| Rate for Payer: Quartz Commercial |
$1,132.95
|
| Rate for Payer: Quartz Medicare Advantage |
$1,045.80
|
| Rate for Payer: The Alliance Commercial |
$6,972.00
|
| Rate for Payer: WEA Trust Commercial |
$958.65
|
| Rate for Payer: WPS Commercial |
$1,291.04
|
|
|
Inj Myleogram
|
Facility
|
IP
|
$1,743.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
3072746
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$854.07 |
| Max. Negotiated Rate |
$1,603.56 |
| Rate for Payer: Aetna Commercial |
$1,568.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,498.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$923.79
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cigna Commercial |
$1,603.56
|
| Rate for Payer: Health EOS Commercial |
$1,551.27
|
| Rate for Payer: HFN Commercial |
$1,603.56
|
| Rate for Payer: Multiplan Commercial |
$1,394.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,045.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,603.56
|
| Rate for Payer: Quartz Beloit One Network |
$854.07
|
| Rate for Payer: Quartz Commercial |
$1,045.80
|
| Rate for Payer: WEA Trust Commercial |
$958.65
|
| Rate for Payer: WPS Commercial |
$1,291.04
|
|
|
Inj Myleogram
|
Professional
|
Both
|
$1,743.00
|
|
|
Service Code
|
CPT 62284
|
| Hospital Charge Code |
3072746
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$192.65 |
| Max. Negotiated Rate |
$1,655.85 |
| Rate for Payer: Aetna Commercial |
$1,655.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,498.98
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cash Price |
$522.90
|
| Rate for Payer: Cigna Commercial |
$1,655.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$192.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,045.80
|
| Rate for Payer: Health EOS Commercial |
$1,586.13
|
| Rate for Payer: HFN Commercial |
$1,655.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$285.22
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$285.22
|
| Rate for Payer: Multiplan Commercial |
$1,394.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,655.85
|
| Rate for Payer: Quartz Beloit One Network |
$766.92
|
| Rate for Payer: Quartz Commercial |
$993.51
|
| Rate for Payer: The Alliance Commercial |
$871.50
|
| Rate for Payer: United Healthcare Medicaid |
$192.65
|
| Rate for Payer: WEA Trust Commercial |
$958.65
|
| Rate for Payer: WPS Commercial |
$1,291.04
|
|
|
Inj Nephrostogram
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
4406586
|
|
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
|
|
|
Inj Nephrostogram
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
4406586
|
|
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 Nephrostogram
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
CPT 51600
|
| Hospital Charge Code |
4406586
|
|
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 paravert f inj l/s 3 lev 64495-50
|
Professional
|
Both
|
$1,397.00
|
|
|
Service Code
|
CPT 64495 50
|
| Hospital Charge Code |
5355251
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.70 |
| Max. Negotiated Rate |
$1,327.15 |
| Rate for Payer: Aetna Commercial |
$1,327.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,201.42
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cash Price |
$419.10
|
| Rate for Payer: Cigna Commercial |
$1,327.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$838.20
|
| Rate for Payer: Health EOS Commercial |
$1,271.27
|
| Rate for Payer: HFN Commercial |
$1,327.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$176.71
|
| Rate for Payer: Multiplan Commercial |
$1,117.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,327.15
|
| Rate for Payer: Quartz Beloit One Network |
$614.68
|
| Rate for Payer: Quartz Commercial |
$796.29
|
| Rate for Payer: The Alliance Commercial |
$698.50
|
| Rate for Payer: United Healthcare Medicaid |
$61.70
|
| Rate for Payer: WEA Trust Commercial |
$768.35
|
| Rate for Payer: WPS Commercial |
$1,034.76
|
|
|
Inj paravert f jnt l/s 1 lev 64493
|
Professional
|
Both
|
$1,123.00
|
|
|
Service Code
|
CPT 64493
|
| Hospital Charge Code |
3015193
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$124.05 |
| Max. Negotiated Rate |
$1,066.85 |
| Rate for Payer: Aetna Commercial |
$1,066.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$965.78
|
| Rate for Payer: Cash Price |
$336.90
|
| Rate for Payer: Cash Price |
$336.90
|
| Rate for Payer: Cash Price |
$336.90
|
| Rate for Payer: Cigna Commercial |
$1,066.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$124.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$673.80
|
| Rate for Payer: Health EOS Commercial |
$1,021.93
|
| Rate for Payer: HFN Commercial |
$1,066.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$305.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$305.24
|
| Rate for Payer: Multiplan Commercial |
$898.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,066.85
|
| Rate for Payer: Quartz Beloit One Network |
$494.12
|
| Rate for Payer: Quartz Commercial |
$640.11
|
| Rate for Payer: The Alliance Commercial |
$561.50
|
| Rate for Payer: United Healthcare Medicaid |
$124.05
|
| Rate for Payer: WEA Trust Commercial |
$617.65
|
| Rate for Payer: WPS Commercial |
$831.81
|
|
|
Inj paravert f jnt l/s 2 lev 64494
|
Professional
|
Both
|
$687.00
|
|
|
Service Code
|
CPT 64494
|
| Hospital Charge Code |
3015194
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$60.80 |
| Max. Negotiated Rate |
$652.65 |
| Rate for Payer: Aetna Commercial |
$652.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$590.82
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Cigna Commercial |
$652.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$60.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$412.20
|
| Rate for Payer: Health EOS Commercial |
$625.17
|
| Rate for Payer: HFN Commercial |
$652.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.38
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$174.38
|
| Rate for Payer: Multiplan Commercial |
$549.60
|
| Rate for Payer: Preferred Network Access Commercial |
$652.65
|
| Rate for Payer: Quartz Beloit One Network |
$302.28
|
| Rate for Payer: Quartz Commercial |
$391.59
|
| Rate for Payer: The Alliance Commercial |
$343.50
|
| Rate for Payer: United Healthcare Medicaid |
$60.80
|
| Rate for Payer: WEA Trust Commercial |
$377.85
|
| Rate for Payer: WPS Commercial |
$508.86
|
|
|
Inj paravert f jnt l/s 3 lev 64495
|
Professional
|
Both
|
$699.00
|
|
|
Service Code
|
CPT 64495
|
| Hospital Charge Code |
3015195
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.70 |
| Max. Negotiated Rate |
$664.05 |
| Rate for Payer: Aetna Commercial |
$664.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$601.14
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cigna Commercial |
$664.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.40
|
| Rate for Payer: Health EOS Commercial |
$636.09
|
| Rate for Payer: HFN Commercial |
$664.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$176.71
|
| Rate for Payer: Multiplan Commercial |
$559.20
|
| Rate for Payer: Preferred Network Access Commercial |
$664.05
|
| Rate for Payer: Quartz Beloit One Network |
$307.56
|
| Rate for Payer: Quartz Commercial |
$398.43
|
| Rate for Payer: The Alliance Commercial |
$349.50
|
| Rate for Payer: United Healthcare Medicaid |
$61.70
|
| Rate for Payer: WEA Trust Commercial |
$384.45
|
| Rate for Payer: WPS Commercial |
$517.75
|
|
|
Inj, Penicillin G Benz and Pen G Procaine J0558
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
4027271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$18.40 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.60
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$18.40
|
| Rate for Payer: Health EOS Commercial |
$17.80
|
| Rate for Payer: HFN Commercial |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$16.00
|
| Rate for Payer: NAPHCARE Commercial |
$12.00
|
| Rate for Payer: Preferred Network Access Commercial |
$18.40
|
| Rate for Payer: Quartz Beloit One Network |
$9.80
|
| Rate for Payer: Quartz Commercial |
$12.00
|
| Rate for Payer: WEA Trust Commercial |
$11.00
|
| Rate for Payer: WPS Commercial |
$14.81
|
|
|
Inj, Penicillin G Benz and Pen G Procaine J0558
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
4027271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$43.42 |
| Rate for Payer: Aetna Commercial |
$19.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.37
|
| Rate for Payer: Health EOS Commercial |
$18.20
|
| Rate for Payer: HFN Commercial |
$19.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.61
|
| Rate for Payer: Multiplan Commercial |
$16.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19.00
|
| Rate for Payer: Quartz Beloit One Network |
$8.80
|
| Rate for Payer: Quartz Commercial |
$11.40
|
| Rate for Payer: The Alliance Commercial |
$10.00
|
| Rate for Payer: United Healthcare Medicaid |
$17.37
|
| Rate for Payer: WEA Trust Commercial |
$11.00
|
| Rate for Payer: WPS Commercial |
$43.42
|
|
|
Inj, Penicillin G Benz and Pen G Procaine J0558
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS J0558
|
| Hospital Charge Code |
4027271
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$70.31 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.20
|
| Rate for Payer: Aetna Managed Medicare |
$17.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.60
|
| Rate for Payer: Anthem Medicare Advantage |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.58
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$18.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.58
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.98
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.58
|
| Rate for Payer: Health EOS Commercial |
$17.80
|
| Rate for Payer: HFN Commercial |
$18.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.58
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.58
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.58
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.58
|
| Rate for Payer: Multiplan Commercial |
$16.00
|
| Rate for Payer: NAPHCARE Commercial |
$26.37
|
| Rate for Payer: Preferred Network Access Commercial |
$18.40
|
| Rate for Payer: Quartz Beloit One Network |
$9.80
|
| Rate for Payer: Quartz Commercial |
$13.00
|
| Rate for Payer: Quartz Medicare Advantage |
$17.58
|
| Rate for Payer: The Alliance Commercial |
$70.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.58
|
| Rate for Payer: WEA Trust Commercial |
$11.00
|
| Rate for Payer: Wellcare Medicare |
$17.58
|
| Rate for Payer: WPS Commercial |
$43.42
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.41 |
| Max. Negotiated Rate |
$8.28 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$5.40
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.40
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$6.67
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Professional
|
Both
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$8.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$21.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.00
|
| Rate for Payer: Health EOS Commercial |
$8.19
|
| Rate for Payer: HFN Commercial |
$8.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.24
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8.55
|
| Rate for Payer: Quartz Beloit One Network |
$3.96
|
| Rate for Payer: Quartz Commercial |
$5.13
|
| Rate for Payer: The Alliance Commercial |
$4.50
|
| Rate for Payer: United Healthcare Medicaid |
$21.73
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Inj Penicillin G Benzathine up to 100,000 U J0561
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
4008560
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.32 |
| Max. Negotiated Rate |
$86.92 |
| Rate for Payer: Aetna Commercial |
$8.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.74
|
| Rate for Payer: Aetna Managed Medicare |
$21.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.32
|
| Rate for Payer: Anthem Medicare Advantage |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$21.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$21.73
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.28
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$21.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.10
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$21.73
|
| Rate for Payer: Health EOS Commercial |
$8.01
|
| Rate for Payer: HFN Commercial |
$8.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$21.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$21.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$21.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$21.73
|
| Rate for Payer: Multiplan Commercial |
$7.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.60
|
| Rate for Payer: Preferred Network Access Commercial |
$8.28
|
| Rate for Payer: Quartz Beloit One Network |
$4.41
|
| Rate for Payer: Quartz Commercial |
$5.85
|
| Rate for Payer: Quartz Medicare Advantage |
$21.73
|
| Rate for Payer: The Alliance Commercial |
$86.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$21.73
|
| Rate for Payer: WEA Trust Commercial |
$4.95
|
| Rate for Payer: Wellcare Medicare |
$21.73
|
| Rate for Payer: WPS Commercial |
$55.00
|
|
|
Inj Procedure For Ductogram
|
Facility
|
IP
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$505.19 |
| Max. Negotiated Rate |
$948.52 |
| Rate for Payer: Aetna Commercial |
$927.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.43
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$948.52
|
| Rate for Payer: Health EOS Commercial |
$917.59
|
| Rate for Payer: HFN Commercial |
$948.52
|
| Rate for Payer: Multiplan Commercial |
$824.80
|
| Rate for Payer: NAPHCARE Commercial |
$618.60
|
| Rate for Payer: Preferred Network Access Commercial |
$948.52
|
| Rate for Payer: Quartz Beloit One Network |
$505.19
|
| Rate for Payer: Quartz Commercial |
$618.60
|
| Rate for Payer: WEA Trust Commercial |
$567.05
|
| Rate for Payer: WPS Commercial |
$763.66
|
|
|
Inj Procedure For Ductogram
|
Facility
|
OP
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$288.68 |
| Max. Negotiated Rate |
$4,218.22 |
| Rate for Payer: Aetna Commercial |
$927.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.66
|
| Rate for Payer: Aetna Managed Medicare |
$288.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$670.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$515.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$494.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$546.43
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$948.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$917.59
|
| Rate for Payer: HFN Commercial |
$948.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$773.25
|
| Rate for Payer: Multiplan Commercial |
$824.80
|
| Rate for Payer: NAPHCARE Commercial |
$618.60
|
| Rate for Payer: Preferred Network Access Commercial |
$948.52
|
| Rate for Payer: Quartz Beloit One Network |
$505.19
|
| Rate for Payer: Quartz Commercial |
$670.15
|
| Rate for Payer: Quartz Medicare Advantage |
$618.60
|
| Rate for Payer: The Alliance Commercial |
$4,124.00
|
| Rate for Payer: WEA Trust Commercial |
$567.05
|
| Rate for Payer: WPS Commercial |
$763.66
|
|
|
Inj Procedure For Ductogram
|
Professional
|
Both
|
$1,031.00
|
|
|
Service Code
|
CPT 19030
|
| Hospital Charge Code |
3072760
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$38.32 |
| Max. Negotiated Rate |
$979.45 |
| Rate for Payer: Aetna Commercial |
$979.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$886.66
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cash Price |
$309.30
|
| Rate for Payer: Cigna Commercial |
$979.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$38.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$618.60
|
| Rate for Payer: Health EOS Commercial |
$938.21
|
| Rate for Payer: HFN Commercial |
$979.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$257.02
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$257.02
|
| Rate for Payer: Multiplan Commercial |
$824.80
|
| Rate for Payer: Preferred Network Access Commercial |
$979.45
|
| Rate for Payer: Quartz Beloit One Network |
$453.64
|
| Rate for Payer: Quartz Commercial |
$587.67
|
| Rate for Payer: The Alliance Commercial |
$515.50
|
| Rate for Payer: United Healthcare Medicaid |
$38.32
|
| Rate for Payer: WEA Trust Commercial |
$567.05
|
| Rate for Payer: WPS Commercial |
$763.66
|
|
|
Inj Procedure Venogram
|
Facility
|
IP
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$644.84 |
| Max. Negotiated Rate |
$1,210.72 |
| Rate for Payer: Aetna Commercial |
$1,184.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,131.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$697.48
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,210.72
|
| Rate for Payer: Health EOS Commercial |
$1,171.24
|
| Rate for Payer: HFN Commercial |
$1,210.72
|
| Rate for Payer: Multiplan Commercial |
$1,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,210.72
|
| Rate for Payer: Quartz Beloit One Network |
$644.84
|
| Rate for Payer: Quartz Commercial |
$789.60
|
| Rate for Payer: WEA Trust Commercial |
$723.80
|
| Rate for Payer: WPS Commercial |
$974.76
|
|
|
Inj Procedure Venogram
|
Facility
|
OP
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$301.00 |
| Max. Negotiated Rate |
$5,264.00 |
| Rate for Payer: Aetna Commercial |
$1,184.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,131.76
|
| Rate for Payer: Aetna Managed Medicare |
$368.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$855.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$658.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$631.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$697.48
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,210.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Health EOS Commercial |
$1,171.24
|
| Rate for Payer: HFN Commercial |
$1,210.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$987.00
|
| Rate for Payer: Multiplan Commercial |
$1,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$789.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,210.72
|
| Rate for Payer: Quartz Beloit One Network |
$644.84
|
| Rate for Payer: Quartz Commercial |
$855.40
|
| Rate for Payer: Quartz Medicare Advantage |
$789.60
|
| Rate for Payer: The Alliance Commercial |
$5,264.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$723.80
|
| Rate for Payer: WPS Commercial |
$974.76
|
|
|
Inj Procedure Venogram
|
Professional
|
Both
|
$1,316.00
|
|
|
Service Code
|
CPT 36005
|
| Hospital Charge Code |
3072647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.13 |
| Max. Negotiated Rate |
$1,250.20 |
| Rate for Payer: Aetna Commercial |
$1,250.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,131.76
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cigna Commercial |
$1,250.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$50.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$789.60
|
| Rate for Payer: Health EOS Commercial |
$1,197.56
|
| Rate for Payer: HFN Commercial |
$1,250.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$157.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$157.30
|
| Rate for Payer: Multiplan Commercial |
$1,052.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,250.20
|
| Rate for Payer: Quartz Beloit One Network |
$579.04
|
| Rate for Payer: Quartz Commercial |
$750.12
|
| Rate for Payer: The Alliance Commercial |
$658.00
|
| Rate for Payer: United Healthcare Medicaid |
$50.13
|
| Rate for Payer: WEA Trust Commercial |
$723.80
|
| Rate for Payer: WPS Commercial |
$974.76
|
|
