|
OMNIPAQUE 300 100ml VIAL [MED]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
5286883
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$95.68 |
| Rate for Payer: Aetna Commercial |
$93.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$89.44
|
| Rate for Payer: Aetna Managed Medicare |
$29.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$67.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$52.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$49.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$55.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$95.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$92.56
|
| Rate for Payer: HFN Commercial |
$95.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$78.00
|
| Rate for Payer: Multiplan Commercial |
$83.20
|
| Rate for Payer: NAPHCARE Commercial |
$62.40
|
| Rate for Payer: Preferred Network Access Commercial |
$95.68
|
| Rate for Payer: Quartz Beloit One Network |
$50.96
|
| Rate for Payer: Quartz Commercial |
$67.60
|
| Rate for Payer: Quartz Medicare Advantage |
$62.40
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$57.20
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 300 150ml
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2950268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$282.57 |
| Rate for Payer: Aetna Commercial |
$282.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$282.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$270.67
|
| Rate for Payer: HFN Commercial |
$282.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$282.57
|
| Rate for Payer: Quartz Beloit One Network |
$130.87
|
| Rate for Payer: Quartz Commercial |
$169.54
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 300 150ml
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2950268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.75 |
| Max. Negotiated Rate |
$273.64 |
| Rate for Payer: Aetna Commercial |
$267.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.64
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$273.64
|
| Rate for Payer: Health EOS Commercial |
$264.72
|
| Rate for Payer: HFN Commercial |
$273.64
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: Preferred Network Access Commercial |
$273.64
|
| Rate for Payer: Quartz Beloit One Network |
$145.75
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$220.31
|
|
|
Omnipaque 300 150ml
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2950268
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$273.64 |
| Rate for Payer: Aetna Commercial |
$267.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$83.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$193.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.64
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$273.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$264.72
|
| Rate for Payer: HFN Commercial |
$273.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.08
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$178.46
|
| Rate for Payer: Preferred Network Access Commercial |
$273.64
|
| Rate for Payer: Quartz Beloit One Network |
$145.75
|
| Rate for Payer: Quartz Commercial |
$193.34
|
| Rate for Payer: Quartz Medicare Advantage |
$178.46
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 300 50ml
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$52.36 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$52.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$50.16
|
| Rate for Payer: HFN Commercial |
$52.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$52.36
|
| Rate for Payer: Quartz Beloit One Network |
$24.25
|
| Rate for Payer: Quartz Commercial |
$31.42
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 300 50ml
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
Omnipaque 300 50ml
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158852
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
OMNIPAQUE 300 50ml VIAL [MED]
|
Facility
|
IP
|
$77.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
2975369
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$39.24 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$48.05
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
OMNIPAQUE 300 50ml VIAL [MED]
|
Facility
|
OP
|
$77.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
2975369
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$73.67 |
| Rate for Payer: Aetna Commercial |
$72.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$68.87
|
| Rate for Payer: Aetna Managed Medicare |
$22.42
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$52.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$40.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$38.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$42.44
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna Commercial |
$73.67
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.53
|
| Rate for Payer: Health EOS Commercial |
$71.27
|
| Rate for Payer: HFN Commercial |
$73.67
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$60.06
|
| Rate for Payer: Multiplan Commercial |
$64.06
|
| Rate for Payer: NAPHCARE Commercial |
$48.05
|
| Rate for Payer: Preferred Network Access Commercial |
$73.67
|
| Rate for Payer: Quartz Beloit One Network |
$39.24
|
| Rate for Payer: Quartz Commercial |
$52.05
|
| Rate for Payer: Quartz Medicare Advantage |
$48.05
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$44.04
|
| Rate for Payer: WPS Commercial |
$59.31
|
|
|
Omnipaque 350 100ml
|
Facility
|
OP
|
$105.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$30.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.98
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.90
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$65.52
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$70.98
|
| Rate for Payer: Quartz Medicare Advantage |
$65.52
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 350 100ml
|
Facility
|
IP
|
$105.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$100.46 |
| Rate for Payer: Aetna Commercial |
$98.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.88
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$100.46
|
| Rate for Payer: Health EOS Commercial |
$97.19
|
| Rate for Payer: HFN Commercial |
$100.46
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: Preferred Network Access Commercial |
$100.46
|
| Rate for Payer: Quartz Beloit One Network |
$53.51
|
| Rate for Payer: Quartz Commercial |
$65.52
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$80.88
|
|
|
Omnipaque 350 100ml
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$103.74 |
| Rate for Payer: Aetna Commercial |
$103.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.91
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: Cigna Commercial |
$103.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$99.37
|
| Rate for Payer: HFN Commercial |
$103.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$87.36
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$103.74
|
| Rate for Payer: Quartz Beloit One Network |
$48.05
|
| Rate for Payer: Quartz Commercial |
$62.24
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$60.06
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 350 150 ml
|
Professional
|
Both
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$282.57 |
| Rate for Payer: Aetna Commercial |
$282.57
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$282.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$270.67
|
| Rate for Payer: HFN Commercial |
$282.57
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$282.57
|
| Rate for Payer: Quartz Beloit One Network |
$130.87
|
| Rate for Payer: Quartz Commercial |
$169.54
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 350 150 ml
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$273.64 |
| Rate for Payer: Aetna Commercial |
$267.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Aetna Managed Medicare |
$83.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$193.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$148.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$142.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.64
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$273.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$264.72
|
| Rate for Payer: HFN Commercial |
$273.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$223.08
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: NAPHCARE Commercial |
$178.46
|
| Rate for Payer: Preferred Network Access Commercial |
$273.64
|
| Rate for Payer: Quartz Beloit One Network |
$145.75
|
| Rate for Payer: Quartz Commercial |
$193.34
|
| Rate for Payer: Quartz Medicare Advantage |
$178.46
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 350 150 ml
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$145.75 |
| Max. Negotiated Rate |
$273.64 |
| Rate for Payer: Aetna Commercial |
$267.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$255.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$157.64
|
| Rate for Payer: Cash Price |
$85.80
|
| Rate for Payer: Cigna Commercial |
$273.64
|
| Rate for Payer: Health EOS Commercial |
$264.72
|
| Rate for Payer: HFN Commercial |
$273.64
|
| Rate for Payer: Multiplan Commercial |
$237.95
|
| Rate for Payer: Preferred Network Access Commercial |
$273.64
|
| Rate for Payer: Quartz Beloit One Network |
$145.75
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: WEA Trust Commercial |
$163.59
|
| Rate for Payer: WPS Commercial |
$220.31
|
|
|
Omnipaque 350 50 ml
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 350 50 ml
|
Facility
|
IP
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
Omnipaque 350 50 ml
|
Professional
|
Both
|
$53.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2826800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$52.36 |
| Rate for Payer: Aetna Commercial |
$52.36
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$52.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$50.16
|
| Rate for Payer: HFN Commercial |
$52.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$52.36
|
| Rate for Payer: Quartz Beloit One Network |
$24.25
|
| Rate for Payer: Quartz Commercial |
$31.42
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$119.55 |
| Rate for Payer: Aetna Commercial |
$119.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$119.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$114.51
|
| Rate for Payer: HFN Commercial |
$119.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$119.55
|
| Rate for Payer: Quartz Beloit One Network |
$55.37
|
| Rate for Payer: Quartz Commercial |
$71.73
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.64 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$74.26
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$91.67
|
|
|
Omnipaque 50cc
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.66 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$75.50
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$93.21
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550878
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$115.77 |
| Rate for Payer: Aetna Commercial |
$113.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$108.22
|
| Rate for Payer: Aetna Managed Medicare |
$35.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$60.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.70
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$115.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$112.00
|
| Rate for Payer: HFN Commercial |
$115.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$94.38
|
| Rate for Payer: Multiplan Commercial |
$100.67
|
| Rate for Payer: NAPHCARE Commercial |
$75.50
|
| Rate for Payer: Preferred Network Access Commercial |
$115.77
|
| Rate for Payer: Quartz Beloit One Network |
$61.66
|
| Rate for Payer: Quartz Commercial |
$81.80
|
| Rate for Payer: Quartz Medicare Advantage |
$75.50
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$69.21
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omnipaque 50cc
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$113.86 |
| Rate for Payer: Aetna Commercial |
$111.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.43
|
| Rate for Payer: Aetna Managed Medicare |
$34.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.44
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.59
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$113.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$110.15
|
| Rate for Payer: HFN Commercial |
$113.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.82
|
| Rate for Payer: Multiplan Commercial |
$99.01
|
| Rate for Payer: NAPHCARE Commercial |
$74.26
|
| Rate for Payer: Preferred Network Access Commercial |
$113.86
|
| Rate for Payer: Quartz Beloit One Network |
$60.64
|
| Rate for Payer: Quartz Commercial |
$80.44
|
| Rate for Payer: Quartz Medicare Advantage |
$74.26
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$68.07
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Omniscan 10ml
|
Facility
|
IP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$131.48 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$160.99
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
|
Omniscan 10ml
|
Facility
|
OP
|
$258.00
|
|
| Hospital Charge Code |
1486800
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.13 |
| Max. Negotiated Rate |
$246.85 |
| Rate for Payer: Aetna Commercial |
$241.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$230.76
|
| Rate for Payer: Aetna Managed Medicare |
$75.13
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$174.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$134.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$128.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$142.21
|
| Rate for Payer: Cash Price |
$77.40
|
| Rate for Payer: Cigna Commercial |
$246.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$150.16
|
| Rate for Payer: Health EOS Commercial |
$238.80
|
| Rate for Payer: HFN Commercial |
$246.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$201.24
|
| Rate for Payer: Multiplan Commercial |
$214.66
|
| Rate for Payer: NAPHCARE Commercial |
$160.99
|
| Rate for Payer: Preferred Network Access Commercial |
$246.85
|
| Rate for Payer: Quartz Beloit One Network |
$131.48
|
| Rate for Payer: Quartz Commercial |
$174.41
|
| Rate for Payer: Quartz Medicare Advantage |
$160.99
|
| Rate for Payer: The Alliance Commercial |
$134.16
|
| Rate for Payer: WEA Trust Commercial |
$147.58
|
| Rate for Payer: WPS Commercial |
$198.74
|
|
