|
LENS SN60AT 30.0
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2975070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,409.73 |
| Max. Negotiated Rate |
$2,646.84 |
| Rate for Payer: Aetna Commercial |
$2,589.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,474.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,524.81
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,646.84
|
| Rate for Payer: Health EOS Commercial |
$2,560.53
|
| Rate for Payer: HFN Commercial |
$2,646.84
|
| Rate for Payer: Multiplan Commercial |
$2,301.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,726.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,646.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,409.73
|
| Rate for Payer: Quartz Commercial |
$1,726.20
|
| Rate for Payer: WEA Trust Commercial |
$1,582.35
|
| Rate for Payer: WPS Commercial |
$2,130.99
|
|
|
LENS SN60AT 30.0
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2975070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$805.56 |
| Max. Negotiated Rate |
$11,508.00 |
| Rate for Payer: Aetna Commercial |
$2,589.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,474.22
|
| Rate for Payer: Aetna Managed Medicare |
$805.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,870.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,438.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,380.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,524.81
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,646.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,609.97
|
| Rate for Payer: Health EOS Commercial |
$2,560.53
|
| Rate for Payer: HFN Commercial |
$2,646.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,157.75
|
| Rate for Payer: Multiplan Commercial |
$2,301.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,726.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,646.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,409.73
|
| Rate for Payer: Quartz Commercial |
$1,870.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,726.20
|
| Rate for Payer: The Alliance Commercial |
$11,508.00
|
| Rate for Payer: WEA Trust Commercial |
$1,582.35
|
| Rate for Payer: WPS Commercial |
$2,130.99
|
|
|
LENS SN60AT 33.0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964590
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,464.61 |
| Max. Negotiated Rate |
$2,749.88 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,793.40
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS SN60AT 33.0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964590
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$11,956.00 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Aetna Managed Medicare |
$836.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,942.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,494.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,434.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,672.64
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,241.75
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,942.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,793.40
|
| Rate for Payer: The Alliance Commercial |
$11,956.00
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS THERAPUTIC MORGAN
|
Facility
|
OP
|
$397.00
|
|
| Hospital Charge Code |
2963015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.16 |
| Max. Negotiated Rate |
$1,588.00 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Aetna Managed Medicare |
$111.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$258.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$198.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$190.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.16
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$297.75
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$258.05
|
| Rate for Payer: Quartz Medicare Advantage |
$238.20
|
| Rate for Payer: The Alliance Commercial |
$1,588.00
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
LENS THERAPUTIC MORGAN
|
Facility
|
IP
|
$397.00
|
|
| Hospital Charge Code |
2963015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$194.53 |
| Max. Negotiated Rate |
$365.24 |
| Rate for Payer: Aetna Commercial |
$357.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$341.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.41
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$365.24
|
| Rate for Payer: Health EOS Commercial |
$353.33
|
| Rate for Payer: HFN Commercial |
$365.24
|
| Rate for Payer: Multiplan Commercial |
$317.60
|
| Rate for Payer: NAPHCARE Commercial |
$238.20
|
| Rate for Payer: Preferred Network Access Commercial |
$365.24
|
| Rate for Payer: Quartz Beloit One Network |
$194.53
|
| Rate for Payer: Quartz Commercial |
$238.20
|
| Rate for Payer: WEA Trust Commercial |
$218.35
|
| Rate for Payer: WPS Commercial |
$294.06
|
|
|
Leptin
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
4163507
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Aetna Managed Medicare |
$14.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$24.71
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$23.44
|
| Rate for Payer: Anthem Medicaid |
$14.59
|
| Rate for Payer: Anthem Medicare Advantage |
$14.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.12
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$78.90
|
| Rate for Payer: Dean Health Medicaid |
$14.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.12
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.12
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$14.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.12
|
| Rate for Payer: Managed Health Services Medicaid |
$15.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.12
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.12
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.18
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14.59
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$91.65
|
| Rate for Payer: Quartz Medicare Advantage |
$14.12
|
| Rate for Payer: The Alliance Commercial |
$56.48
|
| Rate for Payer: United Healthcare Medicaid |
$14.59
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.12
|
| Rate for Payer: United Healthcare PPO |
$105.75
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: Wellcare Medicare |
$14.12
|
| Rate for Payer: WMAP Medicaid |
$14.59
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
Leptin
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
4163507
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$69.09 |
| Max. Negotiated Rate |
$129.72 |
| Rate for Payer: Aetna Commercial |
$126.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$74.73
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$129.72
|
| Rate for Payer: Health EOS Commercial |
$125.49
|
| Rate for Payer: HFN Commercial |
$129.72
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: NAPHCARE Commercial |
$84.60
|
| Rate for Payer: Preferred Network Access Commercial |
$129.72
|
| Rate for Payer: Quartz Beloit One Network |
$69.09
|
| Rate for Payer: Quartz Commercial |
$84.60
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
Leptin
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
4163507
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.84 |
| Max. Negotiated Rate |
$133.95 |
| Rate for Payer: Aetna Commercial |
$133.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$121.26
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$133.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$70.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.60
|
| Rate for Payer: Health EOS Commercial |
$128.31
|
| Rate for Payer: HFN Commercial |
$133.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.84
|
| Rate for Payer: Multiplan Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$133.95
|
| Rate for Payer: Quartz Beloit One Network |
$62.04
|
| Rate for Payer: Quartz Commercial |
$80.37
|
| Rate for Payer: The Alliance Commercial |
$70.50
|
| Rate for Payer: WEA Trust Commercial |
$77.55
|
| Rate for Payer: WPS Commercial |
$104.44
|
|
|
Leptospira PCR / 17875
|
Professional
|
Both
|
$234.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
978007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$102.96 |
| Max. Negotiated Rate |
$222.30 |
| Rate for Payer: Aetna Commercial |
$222.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$222.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$117.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$140.40
|
| Rate for Payer: Health EOS Commercial |
$212.94
|
| Rate for Payer: HFN Commercial |
$222.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: Preferred Network Access Commercial |
$222.30
|
| Rate for Payer: Quartz Beloit One Network |
$102.96
|
| Rate for Payer: Quartz Commercial |
$133.38
|
| Rate for Payer: The Alliance Commercial |
$117.00
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Leptospira PCR / 17875
|
Facility
|
OP
|
$234.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
978007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.95
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$152.10
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$175.50
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Leptospira PCR / 17875
|
Facility
|
IP
|
$234.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
978007
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.66 |
| Max. Negotiated Rate |
$215.28 |
| Rate for Payer: Aetna Commercial |
$210.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$201.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$124.02
|
| Rate for Payer: Cash Price |
$70.20
|
| Rate for Payer: Cigna Commercial |
$215.28
|
| Rate for Payer: Health EOS Commercial |
$208.26
|
| Rate for Payer: HFN Commercial |
$215.28
|
| Rate for Payer: Multiplan Commercial |
$187.20
|
| Rate for Payer: NAPHCARE Commercial |
$140.40
|
| Rate for Payer: Preferred Network Access Commercial |
$215.28
|
| Rate for Payer: Quartz Beloit One Network |
$114.66
|
| Rate for Payer: Quartz Commercial |
$140.40
|
| Rate for Payer: WEA Trust Commercial |
$128.70
|
| Rate for Payer: WPS Commercial |
$173.32
|
|
|
Leqvio (Inclisiran) 1mg J1306
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
6178255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$15.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$15.00
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$18.52
|
|
|
Leqvio (Inclisiran) 1mg J1306
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
6178255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$48.54 |
| Rate for Payer: Aetna Commercial |
$22.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Aetna Managed Medicare |
$12.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$12.00
|
| Rate for Payer: Anthem Medicare Advantage |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$13.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.13
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.13
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$16.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.13
|
| Rate for Payer: Health EOS Commercial |
$22.25
|
| Rate for Payer: HFN Commercial |
$23.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.14
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.13
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.13
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.13
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.13
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.20
|
| Rate for Payer: Preferred Network Access Commercial |
$23.00
|
| Rate for Payer: Quartz Beloit One Network |
$12.25
|
| Rate for Payer: Quartz Commercial |
$16.25
|
| Rate for Payer: Quartz Medicare Advantage |
$12.13
|
| Rate for Payer: The Alliance Commercial |
$48.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.13
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: Wellcare Medicare |
$12.13
|
| Rate for Payer: WPS Commercial |
$30.30
|
|
|
Leqvio (Inclisiran) 1mg J1306
|
Professional
|
Both
|
$25.00
|
|
|
Service Code
|
HCPCS J1306
|
| Hospital Charge Code |
6178255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$30.30 |
| Rate for Payer: Aetna Commercial |
$23.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$21.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cash Price |
$7.50
|
| Rate for Payer: Cigna Commercial |
$23.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.12
|
| Rate for Payer: Health EOS Commercial |
$22.75
|
| Rate for Payer: HFN Commercial |
$23.75
|
| Rate for Payer: Multiplan Commercial |
$20.00
|
| Rate for Payer: Preferred Network Access Commercial |
$23.75
|
| Rate for Payer: Quartz Beloit One Network |
$11.00
|
| Rate for Payer: Quartz Commercial |
$14.25
|
| Rate for Payer: The Alliance Commercial |
$12.50
|
| Rate for Payer: United Healthcare Medicaid |
$12.12
|
| Rate for Payer: WEA Trust Commercial |
$13.75
|
| Rate for Payer: WPS Commercial |
$30.30
|
|
|
LESION REMOVAL VIA A COLONOSCOPY 45385
|
Professional
|
Both
|
$2,777.00
|
|
|
Service Code
|
CPT 45385
|
| Hospital Charge Code |
3014811
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$467.41 |
| Max. Negotiated Rate |
$2,638.15 |
| Rate for Payer: Aetna Commercial |
$2,638.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,388.22
|
| Rate for Payer: Cash Price |
$833.10
|
| Rate for Payer: Cash Price |
$833.10
|
| Rate for Payer: Cash Price |
$833.10
|
| Rate for Payer: Cigna Commercial |
$2,638.15
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$467.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,666.20
|
| Rate for Payer: Health EOS Commercial |
$2,527.07
|
| Rate for Payer: HFN Commercial |
$2,638.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$849.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$849.53
|
| Rate for Payer: Multiplan Commercial |
$2,221.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,638.15
|
| Rate for Payer: Quartz Beloit One Network |
$1,221.88
|
| Rate for Payer: Quartz Commercial |
$1,582.89
|
| Rate for Payer: The Alliance Commercial |
$1,388.50
|
| Rate for Payer: United Healthcare Medicaid |
$467.41
|
| Rate for Payer: WEA Trust Commercial |
$1,527.35
|
| Rate for Payer: WPS Commercial |
$2,056.92
|
|
|
LESION REMOVE COLONOSCOPY 45384
|
Professional
|
Both
|
$3,571.00
|
|
|
Service Code
|
CPT 45384
|
| Hospital Charge Code |
3014810
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$404.73 |
| Max. Negotiated Rate |
$3,392.45 |
| Rate for Payer: Aetna Commercial |
$3,392.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,071.06
|
| Rate for Payer: Cash Price |
$1,071.30
|
| Rate for Payer: Cash Price |
$1,071.30
|
| Rate for Payer: Cash Price |
$1,071.30
|
| Rate for Payer: Cigna Commercial |
$3,392.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$404.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,142.60
|
| Rate for Payer: Health EOS Commercial |
$3,249.61
|
| Rate for Payer: HFN Commercial |
$3,392.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$754.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$754.96
|
| Rate for Payer: Multiplan Commercial |
$2,856.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,392.45
|
| Rate for Payer: Quartz Beloit One Network |
$1,571.24
|
| Rate for Payer: Quartz Commercial |
$2,035.47
|
| Rate for Payer: The Alliance Commercial |
$1,785.50
|
| Rate for Payer: United Healthcare Medicaid |
$404.73
|
| Rate for Payer: WEA Trust Commercial |
$1,964.05
|
| Rate for Payer: WPS Commercial |
$2,645.04
|
|
|
Leucovorin 50 mg Charge
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2958829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Aetna Managed Medicare |
$2.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.80
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.50
|
| Rate for Payer: Quartz Medicare Advantage |
$6.00
|
| Rate for Payer: The Alliance Commercial |
$40.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$12.84
|
|
|
Leucovorin 50 mg Charge
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2958829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$9.20 |
| Rate for Payer: Aetna Commercial |
$9.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5.30
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: Health EOS Commercial |
$8.90
|
| Rate for Payer: HFN Commercial |
$9.20
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: NAPHCARE Commercial |
$6.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.20
|
| Rate for Payer: Quartz Beloit One Network |
$4.90
|
| Rate for Payer: Quartz Commercial |
$6.00
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$7.41
|
|
|
Leucovorin 50 mg Charge
|
Professional
|
Both
|
$10.00
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
2958829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Aetna Commercial |
$9.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.60
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cigna Commercial |
$9.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.14
|
| Rate for Payer: Health EOS Commercial |
$9.10
|
| Rate for Payer: HFN Commercial |
$9.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.70
|
| Rate for Payer: Multiplan Commercial |
$8.00
|
| Rate for Payer: Preferred Network Access Commercial |
$9.50
|
| Rate for Payer: Quartz Beloit One Network |
$4.40
|
| Rate for Payer: Quartz Commercial |
$5.70
|
| Rate for Payer: The Alliance Commercial |
$5.00
|
| Rate for Payer: United Healthcare Medicaid |
$4.47
|
| Rate for Payer: WEA Trust Commercial |
$5.50
|
| Rate for Payer: WPS Commercial |
$12.84
|
|
|
Leukemia/Lymphoma Evaluation
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 88189
|
| Hospital Charge Code |
983304
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: United Healthcare PPO |
$86.25
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Leukemia/Lymphoma Evaluation
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
CPT 88189
|
| Hospital Charge Code |
983304
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$288.08 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Anthem Commercial |
$112.18
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$104.65
|
| Rate for Payer: HFN Commercial |
$109.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$288.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$288.08
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: Preferred Network Access Commercial |
$109.25
|
| Rate for Payer: Quartz Beloit One Network |
$50.60
|
| Rate for Payer: Quartz Commercial |
$65.55
|
| Rate for Payer: The Alliance Commercial |
$57.50
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Leukemia/Lymphoma Evaluation
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 88189
|
| Hospital Charge Code |
983304
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Leukotriene E4, Urine
|
Facility
|
IP
|
$1,106.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5841646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$541.94 |
| Max. Negotiated Rate |
$1,017.52 |
| Rate for Payer: Aetna Commercial |
$995.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$586.18
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$1,017.52
|
| Rate for Payer: Health EOS Commercial |
$984.34
|
| Rate for Payer: HFN Commercial |
$1,017.52
|
| Rate for Payer: Multiplan Commercial |
$884.80
|
| Rate for Payer: NAPHCARE Commercial |
$663.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,017.52
|
| Rate for Payer: Quartz Beloit One Network |
$541.94
|
| Rate for Payer: Quartz Commercial |
$663.60
|
| Rate for Payer: WEA Trust Commercial |
$608.30
|
| Rate for Payer: WPS Commercial |
$819.21
|
|
|
Leukotriene E4, Urine
|
Professional
|
Both
|
$1,106.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5841646
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.04 |
| Max. Negotiated Rate |
$1,050.70 |
| Rate for Payer: Aetna Commercial |
$1,050.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$951.16
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cash Price |
$331.80
|
| Rate for Payer: Cigna Commercial |
$1,050.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$553.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$663.60
|
| Rate for Payer: Health EOS Commercial |
$1,006.46
|
| Rate for Payer: HFN Commercial |
$1,050.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.04
|
| Rate for Payer: Multiplan Commercial |
$884.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,050.70
|
| Rate for Payer: Quartz Beloit One Network |
$486.64
|
| Rate for Payer: Quartz Commercial |
$630.42
|
| Rate for Payer: The Alliance Commercial |
$553.00
|
| Rate for Payer: WEA Trust Commercial |
$608.30
|
| Rate for Payer: WPS Commercial |
$819.21
|
|
