|
Urea Nitrogen, Urine
|
Facility
OP
|
$30.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
5474701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$25.80
|
| Rate for Payer: Aetna Managed Medicare |
$5.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.23
|
| Rate for Payer: Anthem Medicaid |
$5.75
|
| Rate for Payer: Anthem Medicare Advantage |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.56
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.75
|
| Rate for Payer: Dean Health Medicaid |
$5.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.56
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$8.34
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.75
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$19.50
|
| Rate for Payer: Quartz Medicare Advantage |
$5.56
|
| Rate for Payer: The Alliance Commercial |
$120.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.56
|
| Rate for Payer: United Healthcare PPO |
$22.50
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: Wellcare Medicare |
$5.56
|
| Rate for Payer: WMAP Medicaid |
$5.75
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Urea Nitrogen, Urine
|
Facility
IP
|
$30.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
5474701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$27.60 |
| Rate for Payer: Aetna Commercial |
$27.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$15.90
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$27.60
|
| Rate for Payer: Health EOS Commercial |
$26.70
|
| Rate for Payer: HFN Commercial |
$27.60
|
| Rate for Payer: Multiplan Commercial |
$24.00
|
| Rate for Payer: NAPHCARE Commercial |
$18.00
|
| Rate for Payer: Preferred Network Access Commercial |
$27.60
|
| Rate for Payer: Quartz Beloit One Network |
$14.70
|
| Rate for Payer: Quartz Commercial |
$18.00
|
| Rate for Payer: WEA Trust Commercial |
$16.50
|
| Rate for Payer: WPS Commercial |
$22.22
|
|
|
Urea Nitrogen, Urine, PDI
|
Professional
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$78.85 |
| Rate for Payer: Aetna Commercial |
$78.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$5.56
|
| Rate for Payer: Anthem Medicare Advantage |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.56
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.56
|
| Rate for Payer: Health EOS Commercial |
$75.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$19.63
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: Preferred Network Access Commercial |
$78.85
|
| Rate for Payer: Quartz Beloit One Network |
$36.52
|
| Rate for Payer: Quartz Commercial |
$47.31
|
| Rate for Payer: Quartz Medicare Advantage |
$5.56
|
| Rate for Payer: The Alliance Commercial |
$21.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.56
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$24.46
|
|
|
Urea Nitrogen, Urine, PDI
|
Facility
OP
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.56 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$71.38
|
| Rate for Payer: Aetna Managed Medicare |
$5.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$20.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.23
|
| Rate for Payer: Anthem Medicaid |
$5.75
|
| Rate for Payer: Anthem Medicare Advantage |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.56
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.75
|
| Rate for Payer: Dean Health Medicaid |
$5.75
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.56
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.68
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.56
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.56
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.56
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$8.34
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.75
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$53.95
|
| Rate for Payer: Quartz Medicare Advantage |
$5.56
|
| Rate for Payer: The Alliance Commercial |
$332.00
|
| Rate for Payer: United Healthcare Medicaid |
$5.75
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.56
|
| Rate for Payer: United Healthcare PPO |
$62.25
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: Wellcare Medicare |
$5.56
|
| Rate for Payer: WMAP Medicaid |
$5.75
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
Urea Nitrogen, Urine, PDI
|
Facility
IP
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.67 |
| Max. Negotiated Rate |
$76.36 |
| Rate for Payer: Aetna Commercial |
$74.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.99
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: Health EOS Commercial |
$73.87
|
| Rate for Payer: HFN Commercial |
$76.36
|
| Rate for Payer: Multiplan Commercial |
$66.40
|
| Rate for Payer: NAPHCARE Commercial |
$49.80
|
| Rate for Payer: Preferred Network Access Commercial |
$76.36
|
| Rate for Payer: Quartz Beloit One Network |
$40.67
|
| Rate for Payer: Quartz Commercial |
$49.80
|
| Rate for Payer: WEA Trust Commercial |
$45.65
|
| Rate for Payer: WPS Commercial |
$61.48
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR 11/13FR X 28MM M0062502000
|
Facility
OP
|
$1,608.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5307023
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$450.24 |
| Max. Negotiated Rate |
$1,479.36 |
| Rate for Payer: Aetna Commercial |
$1,447.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,382.88
|
| Rate for Payer: Aetna Managed Medicare |
$450.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,045.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$804.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$771.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$852.24
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,479.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.84
|
| Rate for Payer: Health EOS Commercial |
$1,431.12
|
| Rate for Payer: HFN Commercial |
$1,479.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,206.00
|
| Rate for Payer: Multiplan Commercial |
$1,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$964.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,479.36
|
| Rate for Payer: Quartz Beloit One Network |
$787.92
|
| Rate for Payer: Quartz Commercial |
$1,045.20
|
| Rate for Payer: Quartz Medicare Advantage |
$964.80
|
| Rate for Payer: WEA Trust Commercial |
$884.40
|
| Rate for Payer: WPS Commercial |
$1,191.05
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR 11/13FR X 28MM M0062502000
|
Facility
IP
|
$1,608.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5307023
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$787.92 |
| Max. Negotiated Rate |
$1,479.36 |
| Rate for Payer: Aetna Commercial |
$1,447.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$852.24
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,479.36
|
| Rate for Payer: Health EOS Commercial |
$1,431.12
|
| Rate for Payer: HFN Commercial |
$1,479.36
|
| Rate for Payer: Multiplan Commercial |
$1,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$964.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,479.36
|
| Rate for Payer: Quartz Beloit One Network |
$787.92
|
| Rate for Payer: Quartz Commercial |
$964.80
|
| Rate for Payer: WEA Trust Commercial |
$884.40
|
| Rate for Payer: WPS Commercial |
$1,191.05
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR 11/13FR X 46MM M0062502040
|
Facility
IP
|
$1,608.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5307024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$787.92 |
| Max. Negotiated Rate |
$1,479.36 |
| Rate for Payer: Aetna Commercial |
$1,447.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$852.24
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,479.36
|
| Rate for Payer: Health EOS Commercial |
$1,431.12
|
| Rate for Payer: HFN Commercial |
$1,479.36
|
| Rate for Payer: Multiplan Commercial |
$1,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$964.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,479.36
|
| Rate for Payer: Quartz Beloit One Network |
$787.92
|
| Rate for Payer: Quartz Commercial |
$964.80
|
| Rate for Payer: WEA Trust Commercial |
$884.40
|
| Rate for Payer: WPS Commercial |
$1,191.05
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR 11/13FR X 46MM M0062502040
|
Facility
OP
|
$1,608.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
5307024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$450.24 |
| Max. Negotiated Rate |
$1,479.36 |
| Rate for Payer: Aetna Commercial |
$1,447.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,382.88
|
| Rate for Payer: Aetna Managed Medicare |
$450.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,045.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$804.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$771.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$852.24
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,479.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$899.84
|
| Rate for Payer: Health EOS Commercial |
$1,431.12
|
| Rate for Payer: HFN Commercial |
$1,479.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,206.00
|
| Rate for Payer: Multiplan Commercial |
$1,286.40
|
| Rate for Payer: NAPHCARE Commercial |
$964.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,479.36
|
| Rate for Payer: Quartz Beloit One Network |
$787.92
|
| Rate for Payer: Quartz Commercial |
$1,045.20
|
| Rate for Payer: Quartz Medicare Advantage |
$964.80
|
| Rate for Payer: WEA Trust Commercial |
$884.40
|
| Rate for Payer: WPS Commercial |
$1,191.05
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 28MM M0062502210
|
Facility
OP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$424.48 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,303.76
|
| Rate for Payer: Aetna Managed Medicare |
$424.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$985.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$758.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$727.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$848.35
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,137.00
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$985.40
|
| Rate for Payer: Quartz Medicare Advantage |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 28MM M0062502210
|
Facility
IP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021629
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$742.84 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 36MM M0062502220
|
Facility
OP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021630
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$424.48 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,303.76
|
| Rate for Payer: Aetna Managed Medicare |
$424.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$985.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$758.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$727.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$848.35
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,137.00
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$985.40
|
| Rate for Payer: Quartz Medicare Advantage |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 36MM M0062502220
|
Facility
IP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021630
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$742.84 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 42MM M0062502230
|
Facility
IP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021631
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$742.84 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 11/13FR X 42MM M0062502230
|
Facility
OP
|
$1,516.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
6021631
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$424.48 |
| Max. Negotiated Rate |
$1,394.72 |
| Rate for Payer: Aetna Commercial |
$1,364.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,303.76
|
| Rate for Payer: Aetna Managed Medicare |
$424.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$985.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$758.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$727.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$803.48
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,394.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$848.35
|
| Rate for Payer: Health EOS Commercial |
$1,349.24
|
| Rate for Payer: HFN Commercial |
$1,394.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,137.00
|
| Rate for Payer: Multiplan Commercial |
$1,212.80
|
| Rate for Payer: NAPHCARE Commercial |
$909.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,394.72
|
| Rate for Payer: Quartz Beloit One Network |
$742.84
|
| Rate for Payer: Quartz Commercial |
$985.40
|
| Rate for Payer: Quartz Medicare Advantage |
$909.60
|
| Rate for Payer: WEA Trust Commercial |
$833.80
|
| Rate for Payer: WPS Commercial |
$1,122.90
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 12/14FR X 28MM M0062502240
|
Facility
IP
|
$1,764.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4595197
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$864.36 |
| Max. Negotiated Rate |
$1,622.88 |
| Rate for Payer: Aetna Commercial |
$1,587.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.92
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cigna Commercial |
$1,622.88
|
| Rate for Payer: Health EOS Commercial |
$1,569.96
|
| Rate for Payer: HFN Commercial |
$1,622.88
|
| Rate for Payer: Multiplan Commercial |
$1,411.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,058.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.88
|
| Rate for Payer: Quartz Beloit One Network |
$864.36
|
| Rate for Payer: Quartz Commercial |
$1,058.40
|
| Rate for Payer: WEA Trust Commercial |
$970.20
|
| Rate for Payer: WPS Commercial |
$1,306.59
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 12/14FR X 28MM M0062502240
|
Facility
OP
|
$1,764.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4595197
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$493.92 |
| Max. Negotiated Rate |
$1,622.88 |
| Rate for Payer: Aetna Commercial |
$1,587.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,517.04
|
| Rate for Payer: Aetna Managed Medicare |
$493.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,146.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$882.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$846.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$934.92
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cigna Commercial |
$1,622.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$987.13
|
| Rate for Payer: Health EOS Commercial |
$1,569.96
|
| Rate for Payer: HFN Commercial |
$1,622.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,323.00
|
| Rate for Payer: Multiplan Commercial |
$1,411.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,058.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.88
|
| Rate for Payer: Quartz Beloit One Network |
$864.36
|
| Rate for Payer: Quartz Commercial |
$1,146.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,058.40
|
| Rate for Payer: WEA Trust Commercial |
$970.20
|
| Rate for Payer: WPS Commercial |
$1,306.59
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 12/14FR X 36MM M0062502250
|
Facility
OP
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4520091
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$512.96 |
| Max. Negotiated Rate |
$1,685.44 |
| Rate for Payer: Aetna Commercial |
$1,648.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,575.52
|
| Rate for Payer: Aetna Managed Medicare |
$512.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,190.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$916.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$879.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$970.96
|
| Rate for Payer: Cash Price |
$549.60
|
| Rate for Payer: Cigna Commercial |
$1,685.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,025.19
|
| Rate for Payer: Health EOS Commercial |
$1,630.48
|
| Rate for Payer: HFN Commercial |
$1,685.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,374.00
|
| Rate for Payer: Multiplan Commercial |
$1,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,099.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,685.44
|
| Rate for Payer: Quartz Beloit One Network |
$897.68
|
| Rate for Payer: Quartz Commercial |
$1,190.80
|
| Rate for Payer: Quartz Medicare Advantage |
$1,099.20
|
| Rate for Payer: WEA Trust Commercial |
$1,007.60
|
| Rate for Payer: WPS Commercial |
$1,356.96
|
|
|
URETERAL ACCESS SHEATH SET NAVIGATOR HD 12/14FR X 36MM M0062502250
|
Facility
IP
|
$1,832.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
4520091
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$897.68 |
| Max. Negotiated Rate |
$1,685.44 |
| Rate for Payer: Aetna Commercial |
$1,648.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$970.96
|
| Rate for Payer: Cash Price |
$549.60
|
| Rate for Payer: Cigna Commercial |
$1,685.44
|
| Rate for Payer: Health EOS Commercial |
$1,630.48
|
| Rate for Payer: HFN Commercial |
$1,685.44
|
| Rate for Payer: Multiplan Commercial |
$1,465.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,099.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,685.44
|
| Rate for Payer: Quartz Beloit One Network |
$897.68
|
| Rate for Payer: Quartz Commercial |
$1,099.20
|
| Rate for Payer: WEA Trust Commercial |
$1,007.60
|
| Rate for Payer: WPS Commercial |
$1,356.96
|
|
|
URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER
|
Facility
OP
|
$12,818.15
|
|
|
Service Code
|
CPT 50953
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,445.74 |
| Max. Negotiated Rate |
$12,818.15 |
| Rate for Payer: Aetna Managed Medicare |
$3,445.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,907.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,043.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,639.00
|
| Rate for Payer: Anthem Medicare Advantage |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,445.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,445.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,445.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,218.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,445.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$12,818.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,445.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,445.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,445.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,445.74
|
| Rate for Payer: NAPHCARE Commercial |
$5,168.61
|
| Rate for Payer: Quartz Medicare Advantage |
$3,445.74
|
| Rate for Payer: The Alliance Commercial |
$5,646.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,445.74
|
| Rate for Payer: United Healthcare PPO |
$4,103.00
|
| Rate for Payer: Wellcare Medicare |
$3,445.74
|
|
|
URETERECTOMY, TOTAL
|
Facility
IP
|
$7,912.00
|
|
| Hospital Charge Code |
2960468
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,876.88 |
| Max. Negotiated Rate |
$7,279.04 |
| Rate for Payer: Aetna Commercial |
$7,120.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,193.36
|
| Rate for Payer: Cash Price |
$2,373.60
|
| Rate for Payer: Cigna Commercial |
$7,279.04
|
| Rate for Payer: Health EOS Commercial |
$7,041.68
|
| Rate for Payer: HFN Commercial |
$7,279.04
|
| Rate for Payer: Multiplan Commercial |
$6,329.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,747.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,279.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,876.88
|
| Rate for Payer: Quartz Commercial |
$4,747.20
|
| Rate for Payer: WEA Trust Commercial |
$4,351.60
|
| Rate for Payer: WPS Commercial |
$5,860.42
|
|
|
URETERECTOMY, TOTAL
|
Facility
OP
|
$7,912.00
|
|
| Hospital Charge Code |
2960468
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,215.36 |
| Max. Negotiated Rate |
$31,648.00 |
| Rate for Payer: Aetna Commercial |
$7,120.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,804.32
|
| Rate for Payer: Aetna Managed Medicare |
$2,215.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,142.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,956.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,797.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,193.36
|
| Rate for Payer: Cash Price |
$2,373.60
|
| Rate for Payer: Cigna Commercial |
$7,279.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,427.56
|
| Rate for Payer: Health EOS Commercial |
$7,041.68
|
| Rate for Payer: HFN Commercial |
$7,279.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,934.00
|
| Rate for Payer: Multiplan Commercial |
$6,329.60
|
| Rate for Payer: NAPHCARE Commercial |
$4,747.20
|
| Rate for Payer: Preferred Network Access Commercial |
$7,279.04
|
| Rate for Payer: Quartz Beloit One Network |
$3,876.88
|
| Rate for Payer: Quartz Commercial |
$5,142.80
|
| Rate for Payer: Quartz Medicare Advantage |
$4,747.20
|
| Rate for Payer: The Alliance Commercial |
$31,648.00
|
| Rate for Payer: WEA Trust Commercial |
$4,351.60
|
| Rate for Payer: WPS Commercial |
$5,860.42
|
|
|
URETEROCOLONIC CONDUIT
|
Facility
IP
|
$4,460.00
|
|
| Hospital Charge Code |
2960471
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,185.40 |
| Max. Negotiated Rate |
$4,103.20 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,676.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
URETEROCOLONIC CONDUIT
|
Facility
OP
|
$4,460.00
|
|
| Hospital Charge Code |
2960471
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,248.80 |
| Max. Negotiated Rate |
$17,840.00 |
| Rate for Payer: Aetna Commercial |
$4,014.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,835.60
|
| Rate for Payer: Aetna Managed Medicare |
$1,248.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,899.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,230.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,140.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,363.80
|
| Rate for Payer: Cash Price |
$1,338.00
|
| Rate for Payer: Cigna Commercial |
$4,103.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,495.82
|
| Rate for Payer: Health EOS Commercial |
$3,969.40
|
| Rate for Payer: HFN Commercial |
$4,103.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,345.00
|
| Rate for Payer: Multiplan Commercial |
$3,568.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,676.00
|
| Rate for Payer: Preferred Network Access Commercial |
$4,103.20
|
| Rate for Payer: Quartz Beloit One Network |
$2,185.40
|
| Rate for Payer: Quartz Commercial |
$2,899.00
|
| Rate for Payer: Quartz Medicare Advantage |
$2,676.00
|
| Rate for Payer: The Alliance Commercial |
$17,840.00
|
| Rate for Payer: WEA Trust Commercial |
$2,453.00
|
| Rate for Payer: WPS Commercial |
$3,303.52
|
|
|
URETEROLITHOTOMY
|
Facility
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960469
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,101.80 |
| Max. Negotiated Rate |
$15,740.00 |
| Rate for Payer: Aetna Commercial |
$3,541.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,384.10
|
| Rate for Payer: Aetna Managed Medicare |
$1,101.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,557.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,967.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,888.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,085.55
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,620.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,202.03
|
| Rate for Payer: Health EOS Commercial |
$3,502.15
|
| Rate for Payer: HFN Commercial |
$3,620.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,951.25
|
| Rate for Payer: Multiplan Commercial |
$3,148.00
|
| Rate for Payer: NAPHCARE Commercial |
$2,361.00
|
| Rate for Payer: Preferred Network Access Commercial |
$3,620.20
|
| Rate for Payer: Quartz Beloit One Network |
$1,928.15
|
| Rate for Payer: Quartz Commercial |
$2,557.75
|
| Rate for Payer: Quartz Medicare Advantage |
$2,361.00
|
| Rate for Payer: The Alliance Commercial |
$15,740.00
|
| Rate for Payer: WEA Trust Commercial |
$2,164.25
|
| Rate for Payer: WPS Commercial |
$2,914.65
|
|
