|
Juven Nutritional Supplement
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
3031443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.81 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$52.42
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Juven Nutritional Supplement
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
3031443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$80.37 |
| Rate for Payer: Aetna Commercial |
$78.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$75.13
|
| Rate for Payer: Aetna Managed Medicare |
$24.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.30
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$80.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.89
|
| Rate for Payer: Health EOS Commercial |
$77.75
|
| Rate for Payer: HFN Commercial |
$80.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.52
|
| Rate for Payer: Multiplan Commercial |
$69.89
|
| Rate for Payer: NAPHCARE Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$80.37
|
| Rate for Payer: Quartz Beloit One Network |
$42.81
|
| Rate for Payer: Quartz Commercial |
$56.78
|
| Rate for Payer: Quartz Medicare Advantage |
$52.42
|
| Rate for Payer: The Alliance Commercial |
$43.68
|
| Rate for Payer: WEA Trust Commercial |
$48.05
|
| Rate for Payer: WPS Commercial |
$64.71
|
|
|
Kangaroo feeding pump - Devices and Equipment
|
Facility
|
IP
|
$215.00
|
|
| Hospital Charge Code |
3002382
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$109.56 |
| Max. Negotiated Rate |
$205.71 |
| Rate for Payer: Aetna Commercial |
$201.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.51
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$205.71
|
| Rate for Payer: Health EOS Commercial |
$199.00
|
| Rate for Payer: HFN Commercial |
$205.71
|
| Rate for Payer: Multiplan Commercial |
$178.88
|
| Rate for Payer: Preferred Network Access Commercial |
$205.71
|
| Rate for Payer: Quartz Beloit One Network |
$109.56
|
| Rate for Payer: Quartz Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$122.98
|
| Rate for Payer: WPS Commercial |
$165.61
|
|
|
Kangaroo feeding pump - Devices and Equipment
|
Facility
|
OP
|
$215.00
|
|
| Hospital Charge Code |
3002382
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$62.61 |
| Max. Negotiated Rate |
$205.71 |
| Rate for Payer: Aetna Commercial |
$201.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$192.30
|
| Rate for Payer: Aetna Managed Medicare |
$62.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$145.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$111.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$118.51
|
| Rate for Payer: Cash Price |
$64.50
|
| Rate for Payer: Cigna Commercial |
$205.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$125.13
|
| Rate for Payer: Health EOS Commercial |
$199.00
|
| Rate for Payer: HFN Commercial |
$205.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$167.70
|
| Rate for Payer: Multiplan Commercial |
$178.88
|
| Rate for Payer: NAPHCARE Commercial |
$134.16
|
| Rate for Payer: Preferred Network Access Commercial |
$205.71
|
| Rate for Payer: Quartz Beloit One Network |
$109.56
|
| Rate for Payer: Quartz Commercial |
$145.34
|
| Rate for Payer: Quartz Medicare Advantage |
$134.16
|
| Rate for Payer: The Alliance Commercial |
$111.80
|
| Rate for Payer: WEA Trust Commercial |
$122.98
|
| Rate for Payer: WPS Commercial |
$165.61
|
|
|
Kappa/Lambda Light Chains Free
|
Professional
|
Both
|
$233.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1096799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$230.20 |
| Rate for Payer: Aetna Commercial |
$230.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.40
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$230.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$121.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$220.51
|
| Rate for Payer: HFN Commercial |
$230.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.40
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$193.86
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$230.20
|
| Rate for Payer: Quartz Beloit One Network |
$106.62
|
| Rate for Payer: Quartz Commercial |
$138.12
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$70.95
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: WEA Trust Commercial |
$133.28
|
| Rate for Payer: WPS Commercial |
$79.03
|
|
|
Kappa/Lambda Light Chains Free
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1096799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$222.93 |
| Rate for Payer: Aetna Commercial |
$218.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.40
|
| Rate for Payer: Aetna Managed Medicare |
$17.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.43
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.81
|
| Rate for Payer: Anthem Medicare Advantage |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.96
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$222.93
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$135.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.96
|
| Rate for Payer: Health EOS Commercial |
$215.66
|
| Rate for Payer: HFN Commercial |
$222.93
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.96
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.96
|
| Rate for Payer: Multiplan Commercial |
$193.86
|
| Rate for Payer: NAPHCARE Commercial |
$26.94
|
| Rate for Payer: Preferred Network Access Commercial |
$222.93
|
| Rate for Payer: Quartz Beloit One Network |
$118.74
|
| Rate for Payer: Quartz Commercial |
$157.51
|
| Rate for Payer: Quartz Medicare Advantage |
$17.96
|
| Rate for Payer: The Alliance Commercial |
$71.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.96
|
| Rate for Payer: United Healthcare PPO |
$181.74
|
| Rate for Payer: WEA Trust Commercial |
$133.28
|
| Rate for Payer: Wellcare Medicare |
$17.96
|
| Rate for Payer: WPS Commercial |
$179.48
|
|
|
Kappa/Lambda Light Chains Free
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
1096799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.74 |
| Max. Negotiated Rate |
$222.93 |
| Rate for Payer: Aetna Commercial |
$218.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$208.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$128.43
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$222.93
|
| Rate for Payer: Health EOS Commercial |
$215.66
|
| Rate for Payer: HFN Commercial |
$222.93
|
| Rate for Payer: Multiplan Commercial |
$193.86
|
| Rate for Payer: Preferred Network Access Commercial |
$222.93
|
| Rate for Payer: Quartz Beloit One Network |
$118.74
|
| Rate for Payer: Quartz Commercial |
$145.39
|
| Rate for Payer: WEA Trust Commercial |
$133.28
|
| Rate for Payer: WPS Commercial |
$179.48
|
|
|
Kappa/Lambda Light Chains Total, Urine
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
983297
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$98.35 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$120.43
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Kappa/Lambda Light Chains Total, Urine
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
983297
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$184.66 |
| Rate for Payer: Aetna Commercial |
$180.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$14.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.75
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.48
|
| Rate for Payer: Anthem Medicare Advantage |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$106.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.14
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$184.66
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.33
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.14
|
| Rate for Payer: Health EOS Commercial |
$178.64
|
| Rate for Payer: HFN Commercial |
$184.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.14
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$184.66
|
| Rate for Payer: Quartz Beloit One Network |
$98.35
|
| Rate for Payer: Quartz Commercial |
$130.47
|
| Rate for Payer: Quartz Medicare Advantage |
$14.14
|
| Rate for Payer: The Alliance Commercial |
$56.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: United Healthcare PPO |
$150.54
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: Wellcare Medicare |
$14.14
|
| Rate for Payer: WPS Commercial |
$148.67
|
|
|
Kappa/Lambda Light Chains Total, Urine
|
Professional
|
Both
|
$193.00
|
|
|
Service Code
|
CPT 83883
|
| Hospital Charge Code |
983297
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$190.68 |
| Rate for Payer: Aetna Commercial |
$190.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$172.62
|
| Rate for Payer: Aetna Managed Medicare |
$14.14
|
| Rate for Payer: Anthem Medicare Advantage |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.14
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$190.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$100.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.14
|
| Rate for Payer: Health EOS Commercial |
$182.66
|
| Rate for Payer: HFN Commercial |
$190.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.93
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.14
|
| Rate for Payer: Multiplan Commercial |
$160.58
|
| Rate for Payer: NAPHCARE Commercial |
$21.22
|
| Rate for Payer: Preferred Network Access Commercial |
$190.68
|
| Rate for Payer: Quartz Beloit One Network |
$88.32
|
| Rate for Payer: Quartz Commercial |
$114.41
|
| Rate for Payer: Quartz Medicare Advantage |
$14.14
|
| Rate for Payer: The Alliance Commercial |
$55.87
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.14
|
| Rate for Payer: WEA Trust Commercial |
$110.40
|
| Rate for Payer: WPS Commercial |
$62.23
|
|
|
KELLER FUNNEL 2 HA-005
|
Facility
|
OP
|
$1,882.00
|
|
| Hospital Charge Code |
5627669
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$548.04 |
| Max. Negotiated Rate |
$1,800.70 |
| Rate for Payer: Aetna Commercial |
$1,761.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,683.26
|
| Rate for Payer: Aetna Managed Medicare |
$548.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,272.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$978.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$939.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,037.36
|
| Rate for Payer: Cash Price |
$564.60
|
| Rate for Payer: Cigna Commercial |
$1,800.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,095.32
|
| Rate for Payer: Health EOS Commercial |
$1,741.98
|
| Rate for Payer: HFN Commercial |
$1,800.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,467.96
|
| Rate for Payer: Multiplan Commercial |
$1,565.82
|
| Rate for Payer: NAPHCARE Commercial |
$1,174.37
|
| Rate for Payer: Preferred Network Access Commercial |
$1,800.70
|
| Rate for Payer: Quartz Beloit One Network |
$959.07
|
| Rate for Payer: Quartz Commercial |
$1,272.23
|
| Rate for Payer: Quartz Medicare Advantage |
$1,174.37
|
| Rate for Payer: The Alliance Commercial |
$978.64
|
| Rate for Payer: WEA Trust Commercial |
$1,076.50
|
| Rate for Payer: WPS Commercial |
$1,449.70
|
|
|
KELLER FUNNEL 2 HA-005
|
Facility
|
IP
|
$1,882.00
|
|
| Hospital Charge Code |
5627669
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$959.07 |
| Max. Negotiated Rate |
$1,800.70 |
| Rate for Payer: Aetna Commercial |
$1,761.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,683.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,037.36
|
| Rate for Payer: Cash Price |
$564.60
|
| Rate for Payer: Cigna Commercial |
$1,800.70
|
| Rate for Payer: Health EOS Commercial |
$1,741.98
|
| Rate for Payer: HFN Commercial |
$1,800.70
|
| Rate for Payer: Multiplan Commercial |
$1,565.82
|
| Rate for Payer: Preferred Network Access Commercial |
$1,800.70
|
| Rate for Payer: Quartz Beloit One Network |
$959.07
|
| Rate for Payer: Quartz Commercial |
$1,174.37
|
| Rate for Payer: WEA Trust Commercial |
$1,076.50
|
| Rate for Payer: WPS Commercial |
$1,449.70
|
|
|
Kenalog 10mg Charge
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
4524852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Aetna Commercial |
$29.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$0.77
|
| Rate for Payer: Anthem Medicare Advantage |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.77
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$29.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.13
|
| Rate for Payer: Health EOS Commercial |
$28.39
|
| Rate for Payer: HFN Commercial |
$29.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.96
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.77
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$1.15
|
| Rate for Payer: Preferred Network Access Commercial |
$29.64
|
| Rate for Payer: Quartz Beloit One Network |
$13.73
|
| Rate for Payer: Quartz Commercial |
$17.78
|
| Rate for Payer: Quartz Medicare Advantage |
$0.77
|
| Rate for Payer: The Alliance Commercial |
$2.12
|
| Rate for Payer: United Healthcare Medicaid |
$0.77
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.77
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$2.82
|
|
|
Kenalog 10mg Charge
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
4524852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Kenalog 10mg Charge
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
HCPCS J3301
|
| Hospital Charge Code |
4524852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.49
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.40
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$18.72
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$18.72
|
| Rate for Payer: The Alliance Commercial |
$3.08
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$2.82
|
|
|
Kenalog JW Waste Charge
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS J3301 JW
|
| Hospital Charge Code |
5246655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Kenalog JW Waste Charge
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS J3301 JW
|
| Hospital Charge Code |
5246655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$22.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.38
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.49
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.28
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$47.42
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$47.42
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$2.82
|
|
|
Kenalog JW Waste Charge
|
Professional
|
Both
|
$76.00
|
|
|
Service Code
|
HCPCS J3301 JW
|
| Hospital Charge Code |
5246655
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$75.09 |
| Rate for Payer: Aetna Commercial |
$75.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$75.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1.13
|
| Rate for Payer: Health EOS Commercial |
$71.93
|
| Rate for Payer: HFN Commercial |
$75.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1.96
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$75.09
|
| Rate for Payer: Quartz Beloit One Network |
$34.78
|
| Rate for Payer: Quartz Commercial |
$45.05
|
| Rate for Payer: The Alliance Commercial |
$39.52
|
| Rate for Payer: United Healthcare Medicaid |
$0.77
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$2.82
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$6.92 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.26
|
| Rate for Payer: Aetna Managed Medicare |
$0.34
|
| Rate for Payer: Anthem Medicare Advantage |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.34
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.73
|
| Rate for Payer: Health EOS Commercial |
$6.62
|
| Rate for Payer: HFN Commercial |
$6.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.99
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.99
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.51
|
| 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: Quartz Medicare Advantage |
$0.34
|
| Rate for Payer: The Alliance Commercial |
$0.94
|
| Rate for Payer: United Healthcare Medicaid |
$0.34
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.34
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| 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 |
$0.34
|
| 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: Anthem Medicare Advantage |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.34
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$0.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$0.34
|
| Rate for Payer: Health EOS Commercial |
$6.48
|
| Rate for Payer: HFN Commercial |
$6.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$0.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$5.82
|
| Rate for Payer: NAPHCARE Commercial |
$0.51
|
| 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 |
$0.34
|
| Rate for Payer: The Alliance Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.34
|
| Rate for Payer: WEA Trust Commercial |
$4.00
|
| Rate for Payer: Wellcare Medicare |
$0.34
|
| Rate for Payer: WPS Commercial |
$1.83
|
|
|
Ketorolac tromethamine inj 15 mg J1885 man
|
Facility
|
IP
|
$7.00
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
3373575
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
Ketorolac Tromethamine Ophth Solution [Med]
|
Facility
|
OP
|
$26.00
|
|
| Hospital Charge Code |
2974952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Aetna Managed Medicare |
$7.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$17.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.33
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15.13
|
| Rate for Payer: Health EOS Commercial |
$24.07
|
| Rate for Payer: HFN Commercial |
$24.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.28
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: NAPHCARE Commercial |
$16.22
|
| Rate for Payer: Preferred Network Access Commercial |
$24.88
|
| Rate for Payer: Quartz Beloit One Network |
$13.25
|
| Rate for Payer: Quartz Commercial |
$17.58
|
| Rate for Payer: Quartz Medicare Advantage |
$16.22
|
| Rate for Payer: The Alliance Commercial |
$13.52
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$20.03
|
|
|
Ketorolac Tromethamine Ophth Solution [Med]
|
Facility
|
IP
|
$26.00
|
|
| Hospital Charge Code |
2974952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$24.88 |
| Rate for Payer: Aetna Commercial |
$24.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$23.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$14.33
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna Commercial |
$24.88
|
| Rate for Payer: Health EOS Commercial |
$24.07
|
| Rate for Payer: HFN Commercial |
$24.88
|
| Rate for Payer: Multiplan Commercial |
$21.63
|
| Rate for Payer: Preferred Network Access Commercial |
$24.88
|
| Rate for Payer: Quartz Beloit One Network |
$13.25
|
| Rate for Payer: Quartz Commercial |
$16.22
|
| Rate for Payer: WEA Trust Commercial |
$14.87
|
| Rate for Payer: WPS Commercial |
$20.03
|
|
|
KEY TRANSONIC KEY314-5
|
Facility
|
OP
|
$2,616.00
|
|
| Hospital Charge Code |
4048790
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$761.78 |
| Max. Negotiated Rate |
$2,502.99 |
| Rate for Payer: Aetna Commercial |
$2,448.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,339.75
|
| Rate for Payer: Aetna Managed Medicare |
$761.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,768.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,360.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,305.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,441.94
|
| Rate for Payer: Cash Price |
$784.80
|
| Rate for Payer: Cigna Commercial |
$2,502.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,522.51
|
| Rate for Payer: Health EOS Commercial |
$2,421.37
|
| Rate for Payer: HFN Commercial |
$2,502.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,040.48
|
| Rate for Payer: Multiplan Commercial |
$2,176.51
|
| Rate for Payer: NAPHCARE Commercial |
$1,632.38
|
| Rate for Payer: Preferred Network Access Commercial |
$2,502.99
|
| Rate for Payer: Quartz Beloit One Network |
$1,333.11
|
| Rate for Payer: Quartz Commercial |
$1,768.42
|
| Rate for Payer: Quartz Medicare Advantage |
$1,632.38
|
| Rate for Payer: The Alliance Commercial |
$1,360.32
|
| Rate for Payer: WEA Trust Commercial |
$1,496.35
|
| Rate for Payer: WPS Commercial |
$2,015.10
|
|
|
KEY TRANSONIC KEY314-5
|
Facility
|
IP
|
$2,616.00
|
|
| Hospital Charge Code |
4048790
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,333.11 |
| Max. Negotiated Rate |
$2,502.99 |
| Rate for Payer: Aetna Commercial |
$2,448.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,339.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,441.94
|
| Rate for Payer: Cash Price |
$784.80
|
| Rate for Payer: Cigna Commercial |
$2,502.99
|
| Rate for Payer: Health EOS Commercial |
$2,421.37
|
| Rate for Payer: HFN Commercial |
$2,502.99
|
| Rate for Payer: Multiplan Commercial |
$2,176.51
|
| Rate for Payer: Preferred Network Access Commercial |
$2,502.99
|
| Rate for Payer: Quartz Beloit One Network |
$1,333.11
|
| Rate for Payer: Quartz Commercial |
$1,632.38
|
| Rate for Payer: WEA Trust Commercial |
$1,496.35
|
| Rate for Payer: WPS Commercial |
$2,015.10
|
|
