|
Omnipaque 350 150 ml
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$271.70 |
| Rate for Payer: Aetna Commercial |
$271.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$271.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$260.26
|
| Rate for Payer: HFN Commercial |
$271.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: Preferred Network Access Commercial |
$271.70
|
| Rate for Payer: Quartz Beloit One Network |
$125.84
|
| Rate for Payer: Quartz Commercial |
$163.02
|
| Rate for Payer: The Alliance Commercial |
$143.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 350 150 ml
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$1,144.00 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Aetna Managed Medicare |
$80.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$214.50
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$185.90
|
| Rate for Payer: Quartz Medicare Advantage |
$171.60
|
| Rate for Payer: The Alliance Commercial |
$1,144.00
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 350 150 ml
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.14 |
| Max. Negotiated Rate |
$263.12 |
| Rate for Payer: Aetna Commercial |
$257.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.58
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$263.12
|
| Rate for Payer: Health EOS Commercial |
$254.54
|
| Rate for Payer: HFN Commercial |
$263.12
|
| Rate for Payer: Multiplan Commercial |
$228.80
|
| Rate for Payer: NAPHCARE Commercial |
$171.60
|
| Rate for Payer: Preferred Network Access Commercial |
$263.12
|
| Rate for Payer: Quartz Beloit One Network |
$140.14
|
| Rate for Payer: Quartz Commercial |
$171.60
|
| Rate for Payer: WEA Trust Commercial |
$157.30
|
| Rate for Payer: WPS Commercial |
$211.84
|
|
|
Omnipaque 350 50 ml
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$50.35 |
| Rate for Payer: Aetna Commercial |
$50.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$48.23
|
| Rate for Payer: HFN Commercial |
$50.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: Preferred Network Access Commercial |
$50.35
|
| Rate for Payer: Quartz Beloit One Network |
$23.32
|
| Rate for Payer: Quartz Commercial |
$30.21
|
| Rate for Payer: The Alliance Commercial |
$26.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 350 50 ml
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
Omnipaque 350 50 ml
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 50cc
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$110.11
|
| Rate for Payer: HFN Commercial |
$114.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: Preferred Network Access Commercial |
$114.95
|
| Rate for Payer: Quartz Beloit One Network |
$53.24
|
| Rate for Payer: Quartz Commercial |
$68.97
|
| Rate for Payer: The Alliance Commercial |
$60.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Aetna Managed Medicare |
$33.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.25
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$77.35
|
| Rate for Payer: Quartz Medicare Advantage |
$71.40
|
| Rate for Payer: The Alliance Commercial |
$476.00
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$33.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$72.60
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$71.40
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
Omniscan 10ml
|
Professional
|
Both
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$113.52 |
| Max. Negotiated Rate |
$245.10 |
| Rate for Payer: Aetna Commercial |
$245.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$245.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$129.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.80
|
| Rate for Payer: Health EOS Commercial |
$234.78
|
| Rate for Payer: HFN Commercial |
$245.10
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: Preferred Network Access Commercial |
$245.10
|
| Rate for Payer: Quartz Beloit One Network |
$113.52
|
| Rate for Payer: Quartz Commercial |
$147.06
|
| Rate for Payer: The Alliance Commercial |
$129.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Omniscan 10ml
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.24 |
| Max. Negotiated Rate |
$1,032.00 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Aetna Managed Medicare |
$72.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$167.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$129.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$123.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.38
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$193.50
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$167.70
|
| Rate for Payer: Quartz Medicare Advantage |
$154.80
|
| Rate for Payer: The Alliance Commercial |
$1,032.00
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Omniscan 10ml
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.42 |
| Max. Negotiated Rate |
$237.36 |
| Rate for Payer: Aetna Commercial |
$232.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$221.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$136.74
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$237.36
|
| Rate for Payer: Health EOS Commercial |
$229.62
|
| Rate for Payer: HFN Commercial |
$237.36
|
| Rate for Payer: Multiplan Commercial |
$206.40
|
| Rate for Payer: NAPHCARE Commercial |
$154.80
|
| Rate for Payer: Preferred Network Access Commercial |
$237.36
|
| Rate for Payer: Quartz Beloit One Network |
$126.42
|
| Rate for Payer: Quartz Commercial |
$154.80
|
| Rate for Payer: WEA Trust Commercial |
$141.90
|
| Rate for Payer: WPS Commercial |
$191.10
|
|
|
Omniscan 15ml
|
Facility
|
OP
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$1,480.00 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Aetna Managed Medicare |
$103.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$240.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$185.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$177.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$207.05
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$277.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$240.50
|
| Rate for Payer: Quartz Medicare Advantage |
$222.00
|
| Rate for Payer: The Alliance Commercial |
$1,480.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Omniscan 15ml
|
Professional
|
Both
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$162.80 |
| Max. Negotiated Rate |
$351.50 |
| Rate for Payer: Aetna Commercial |
$351.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$351.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$185.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.00
|
| Rate for Payer: Health EOS Commercial |
$336.70
|
| Rate for Payer: HFN Commercial |
$351.50
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: Preferred Network Access Commercial |
$351.50
|
| Rate for Payer: Quartz Beloit One Network |
$162.80
|
| Rate for Payer: Quartz Commercial |
$210.90
|
| Rate for Payer: The Alliance Commercial |
$185.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Omniscan 15ml
|
Facility
|
IP
|
$370.00
|
|
| Hospital Charge Code |
1486802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$340.40 |
| Rate for Payer: Aetna Commercial |
$333.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$318.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$196.10
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$340.40
|
| Rate for Payer: Health EOS Commercial |
$329.30
|
| Rate for Payer: HFN Commercial |
$340.40
|
| Rate for Payer: Multiplan Commercial |
$296.00
|
| Rate for Payer: NAPHCARE Commercial |
$222.00
|
| Rate for Payer: Preferred Network Access Commercial |
$340.40
|
| Rate for Payer: Quartz Beloit One Network |
$181.30
|
| Rate for Payer: Quartz Commercial |
$222.00
|
| Rate for Payer: WEA Trust Commercial |
$203.50
|
| Rate for Payer: WPS Commercial |
$274.06
|
|
|
Omniscan 20 ml
|
Facility
|
OP
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$134.96 |
| Max. Negotiated Rate |
$1,928.00 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Aetna Managed Medicare |
$134.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$313.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$241.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$231.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$269.73
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$361.50
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$313.30
|
| Rate for Payer: Quartz Medicare Advantage |
$289.20
|
| Rate for Payer: The Alliance Commercial |
$1,928.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Omniscan 20 ml
|
Professional
|
Both
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$212.08 |
| Max. Negotiated Rate |
$457.90 |
| Rate for Payer: Aetna Commercial |
$457.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$457.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$241.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$289.20
|
| Rate for Payer: Health EOS Commercial |
$438.62
|
| Rate for Payer: HFN Commercial |
$457.90
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: Preferred Network Access Commercial |
$457.90
|
| Rate for Payer: Quartz Beloit One Network |
$212.08
|
| Rate for Payer: Quartz Commercial |
$274.74
|
| Rate for Payer: The Alliance Commercial |
$241.00
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
Omniscan 20 ml
|
Facility
|
IP
|
$482.00
|
|
| Hospital Charge Code |
1486804
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.18 |
| Max. Negotiated Rate |
$443.44 |
| Rate for Payer: Aetna Commercial |
$433.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$414.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$255.46
|
| Rate for Payer: Cash Price |
$144.60
|
| Rate for Payer: Cigna Commercial |
$443.44
|
| Rate for Payer: Health EOS Commercial |
$428.98
|
| Rate for Payer: HFN Commercial |
$443.44
|
| Rate for Payer: Multiplan Commercial |
$385.60
|
| Rate for Payer: NAPHCARE Commercial |
$289.20
|
| Rate for Payer: Preferred Network Access Commercial |
$443.44
|
| Rate for Payer: Quartz Beloit One Network |
$236.18
|
| Rate for Payer: Quartz Commercial |
$289.20
|
| Rate for Payer: WEA Trust Commercial |
$265.10
|
| Rate for Payer: WPS Commercial |
$357.02
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
IP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,631.48 |
| Max. Negotiated Rate |
$8,695.84 |
| Rate for Payer: Aetna Commercial |
$8,506.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.56
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$8,695.84
|
| Rate for Payer: Health EOS Commercial |
$8,412.28
|
| Rate for Payer: HFN Commercial |
$8,695.84
|
| Rate for Payer: Multiplan Commercial |
$7,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.48
|
| Rate for Payer: Quartz Commercial |
$5,671.20
|
| Rate for Payer: WEA Trust Commercial |
$5,198.60
|
| Rate for Payer: WPS Commercial |
$7,001.10
|
|
|
OMNI SURGICAL SYSTEM 1-108
|
Facility
|
OP
|
$9,452.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
6181743
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.56 |
| Max. Negotiated Rate |
$37,808.00 |
| Rate for Payer: Aetna Commercial |
$8,506.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,128.72
|
| Rate for Payer: Aetna Managed Medicare |
$2,646.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,143.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,726.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,536.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,009.56
|
| Rate for Payer: Cash Price |
$2,835.60
|
| Rate for Payer: Cigna Commercial |
$8,695.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,289.34
|
| Rate for Payer: Health EOS Commercial |
$8,412.28
|
| Rate for Payer: HFN Commercial |
$8,695.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,089.00
|
| Rate for Payer: Multiplan Commercial |
$7,561.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,671.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,695.84
|
| Rate for Payer: Quartz Beloit One Network |
$4,631.48
|
| Rate for Payer: Quartz Commercial |
$6,143.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,671.20
|
| Rate for Payer: The Alliance Commercial |
$37,808.00
|
| Rate for Payer: WEA Trust Commercial |
$5,198.60
|
| Rate for Payer: WPS Commercial |
$7,001.10
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
OP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.33 |
| Max. Negotiated Rate |
$1,458.20 |
| Rate for Payer: Aetna Commercial |
$1,426.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.10
|
| Rate for Payer: Aetna Managed Medicare |
$6.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,030.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$792.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$760.80
|
| Rate for Payer: Anthem Medicare Advantage |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.33
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,458.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8.36
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.33
|
| Rate for Payer: Health EOS Commercial |
$1,410.65
|
| Rate for Payer: HFN Commercial |
$1,458.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.54
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.33
|
| Rate for Payer: Multiplan Commercial |
$1,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$9.49
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.20
|
| Rate for Payer: Quartz Beloit One Network |
$776.65
|
| Rate for Payer: Quartz Commercial |
$1,030.25
|
| Rate for Payer: Quartz Medicare Advantage |
$6.33
|
| Rate for Payer: The Alliance Commercial |
$25.31
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.33
|
| Rate for Payer: WEA Trust Commercial |
$871.75
|
| Rate for Payer: Wellcare Medicare |
$6.33
|
| Rate for Payer: WPS Commercial |
$15.80
|
|
|
onabotulinumtoxinA 100 units vial Medical [MED]
|
Facility
|
IP
|
$1,585.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
3393517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$776.65 |
| Max. Negotiated Rate |
$1,458.20 |
| Rate for Payer: Aetna Commercial |
$1,426.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,363.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$840.05
|
| Rate for Payer: Cash Price |
$475.50
|
| Rate for Payer: Cigna Commercial |
$1,458.20
|
| Rate for Payer: Health EOS Commercial |
$1,410.65
|
| Rate for Payer: HFN Commercial |
$1,458.20
|
| Rate for Payer: Multiplan Commercial |
$1,268.00
|
| Rate for Payer: NAPHCARE Commercial |
$951.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,458.20
|
| Rate for Payer: Quartz Beloit One Network |
$776.65
|
| Rate for Payer: Quartz Commercial |
$951.00
|
| Rate for Payer: WEA Trust Commercial |
$871.75
|
| Rate for Payer: WPS Commercial |
$1,174.01
|
|
|
Oncovin 1 mg Charge
|
Professional
|
Both
|
$59.00
|
|
|
Service Code
|
HCPCS J9370
|
| Hospital Charge Code |
2958927
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$56.05 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$50.74
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.91
|
| Rate for Payer: Health EOS Commercial |
$53.69
|
| Rate for Payer: HFN Commercial |
$56.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7.29
|
| Rate for Payer: Multiplan Commercial |
$47.20
|
| Rate for Payer: Preferred Network Access Commercial |
$56.05
|
| Rate for Payer: Quartz Beloit One Network |
$25.96
|
| Rate for Payer: Quartz Commercial |
$33.63
|
| Rate for Payer: The Alliance Commercial |
$29.50
|
| Rate for Payer: United Healthcare Medicaid |
$7.73
|
| Rate for Payer: WEA Trust Commercial |
$32.45
|
| Rate for Payer: WPS Commercial |
$19.78
|
|
