|
Urea Nitrogen Urine
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633857
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$47.42
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Urea Nitrogen Urine
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
CPT 84520
|
| Hospital Charge Code |
633857
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.11 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$71.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.97
|
| Rate for Payer: Aetna Managed Medicare |
$4.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7.19
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6.82
|
| Rate for Payer: Anthem Medicare Advantage |
$4.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$4.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$4.11
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$72.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$4.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.23
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$4.11
|
| Rate for Payer: Health EOS Commercial |
$70.35
|
| Rate for Payer: HFN Commercial |
$72.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$4.11
|
| Rate for Payer: Independent Care Health Plan Medicare |
$4.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$4.11
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$4.11
|
| Rate for Payer: Multiplan Commercial |
$63.23
|
| Rate for Payer: NAPHCARE Commercial |
$6.16
|
| Rate for Payer: Preferred Network Access Commercial |
$72.72
|
| Rate for Payer: Quartz Beloit One Network |
$38.73
|
| Rate for Payer: Quartz Commercial |
$51.38
|
| Rate for Payer: Quartz Medicare Advantage |
$4.11
|
| Rate for Payer: The Alliance Commercial |
$16.43
|
| Rate for Payer: United Healthcare Medicare Advantage |
$4.11
|
| Rate for Payer: United Healthcare PPO |
$59.28
|
| Rate for Payer: WEA Trust Commercial |
$43.47
|
| Rate for Payer: Wellcare Medicare |
$4.11
|
| Rate for Payer: WPS Commercial |
$58.54
|
|
|
Urea Nitrogen, Urine
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
5474701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$5.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.60
|
| Rate for Payer: Anthem Medicare Advantage |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.78
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.46
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.78
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.78
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$8.67
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$20.28
|
| Rate for Payer: Quartz Medicare Advantage |
$5.78
|
| Rate for Payer: The Alliance Commercial |
$23.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: United Healthcare PPO |
$23.40
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: Wellcare Medicare |
$5.78
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Urea Nitrogen, Urine
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
5474701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$29.64 |
| Rate for Payer: Aetna Commercial |
$29.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Aetna Managed Medicare |
$5.78
|
| Rate for Payer: Anthem Medicare Advantage |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.78
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$29.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.78
|
| Rate for Payer: Health EOS Commercial |
$28.39
|
| Rate for Payer: HFN Commercial |
$29.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.78
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: NAPHCARE Commercial |
$8.67
|
| Rate for Payer: Preferred Network Access Commercial |
$29.64
|
| Rate for Payer: Quartz Beloit One Network |
$13.73
|
| Rate for Payer: Quartz Commercial |
$17.78
|
| Rate for Payer: Quartz Medicare Advantage |
$5.78
|
| Rate for Payer: The Alliance Commercial |
$22.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$25.44
|
|
|
Urea Nitrogen, Urine
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
5474701
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.29 |
| Max. Negotiated Rate |
$28.70 |
| Rate for Payer: Aetna Commercial |
$28.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$26.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$16.54
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna Commercial |
$28.70
|
| Rate for Payer: Health EOS Commercial |
$27.77
|
| Rate for Payer: HFN Commercial |
$28.70
|
| Rate for Payer: Multiplan Commercial |
$24.96
|
| Rate for Payer: Preferred Network Access Commercial |
$28.70
|
| Rate for Payer: Quartz Beloit One Network |
$15.29
|
| Rate for Payer: Quartz Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$17.16
|
| Rate for Payer: WPS Commercial |
$23.11
|
|
|
Urea Nitrogen, Urine, PDI
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$51.79
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
Urea Nitrogen, Urine, PDI
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$79.41 |
| Rate for Payer: Aetna Commercial |
$77.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$5.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.60
|
| Rate for Payer: Anthem Medicare Advantage |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$45.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.78
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$79.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.31
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5.78
|
| Rate for Payer: Health EOS Commercial |
$76.82
|
| Rate for Payer: HFN Commercial |
$79.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5.78
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$8.67
|
| Rate for Payer: Preferred Network Access Commercial |
$79.41
|
| Rate for Payer: Quartz Beloit One Network |
$42.30
|
| Rate for Payer: Quartz Commercial |
$56.11
|
| Rate for Payer: Quartz Medicare Advantage |
$5.78
|
| Rate for Payer: The Alliance Commercial |
$23.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: United Healthcare PPO |
$64.74
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: Wellcare Medicare |
$5.78
|
| Rate for Payer: WPS Commercial |
$63.93
|
|
|
Urea Nitrogen, Urine, PDI
|
Professional
|
Both
|
$83.00
|
|
|
Service Code
|
CPT 84540
|
| Hospital Charge Code |
979883
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$82.00 |
| Rate for Payer: Aetna Commercial |
$82.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.24
|
| Rate for Payer: Aetna Managed Medicare |
$5.78
|
| Rate for Payer: Anthem Medicare Advantage |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5.78
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cash Price |
$24.90
|
| Rate for Payer: Cigna Commercial |
$82.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$43.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.78
|
| Rate for Payer: Health EOS Commercial |
$78.55
|
| Rate for Payer: HFN Commercial |
$82.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.42
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5.78
|
| Rate for Payer: Multiplan Commercial |
$69.06
|
| Rate for Payer: NAPHCARE Commercial |
$8.67
|
| Rate for Payer: Preferred Network Access Commercial |
$82.00
|
| Rate for Payer: Quartz Beloit One Network |
$37.98
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: Quartz Medicare Advantage |
$5.78
|
| Rate for Payer: The Alliance Commercial |
$22.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5.78
|
| Rate for Payer: WEA Trust Commercial |
$47.48
|
| Rate for Payer: WPS Commercial |
$25.44
|
|
|
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 |
$468.25 |
| Max. Negotiated Rate |
$1,538.53 |
| Rate for Payer: Aetna Commercial |
$1,505.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,438.20
|
| Rate for Payer: Aetna Managed Medicare |
$468.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,087.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$836.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$802.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$886.33
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,538.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.86
|
| Rate for Payer: Health EOS Commercial |
$1,488.36
|
| Rate for Payer: HFN Commercial |
$1,538.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,254.24
|
| Rate for Payer: Multiplan Commercial |
$1,337.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,003.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.53
|
| Rate for Payer: Quartz Beloit One Network |
$819.44
|
| Rate for Payer: Quartz Commercial |
$1,087.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,003.39
|
| Rate for Payer: The Alliance Commercial |
$836.16
|
| Rate for Payer: WEA Trust Commercial |
$919.78
|
| Rate for Payer: WPS Commercial |
$1,238.64
|
|
|
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 |
$819.44 |
| Max. Negotiated Rate |
$1,538.53 |
| Rate for Payer: Aetna Commercial |
$1,505.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,438.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$886.33
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,538.53
|
| Rate for Payer: Health EOS Commercial |
$1,488.36
|
| Rate for Payer: HFN Commercial |
$1,538.53
|
| Rate for Payer: Multiplan Commercial |
$1,337.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.53
|
| Rate for Payer: Quartz Beloit One Network |
$819.44
|
| Rate for Payer: Quartz Commercial |
$1,003.39
|
| Rate for Payer: WEA Trust Commercial |
$919.78
|
| Rate for Payer: WPS Commercial |
$1,238.64
|
|
|
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 |
$819.44 |
| Max. Negotiated Rate |
$1,538.53 |
| Rate for Payer: Aetna Commercial |
$1,505.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,438.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$886.33
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,538.53
|
| Rate for Payer: Health EOS Commercial |
$1,488.36
|
| Rate for Payer: HFN Commercial |
$1,538.53
|
| Rate for Payer: Multiplan Commercial |
$1,337.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.53
|
| Rate for Payer: Quartz Beloit One Network |
$819.44
|
| Rate for Payer: Quartz Commercial |
$1,003.39
|
| Rate for Payer: WEA Trust Commercial |
$919.78
|
| Rate for Payer: WPS Commercial |
$1,238.64
|
|
|
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 |
$468.25 |
| Max. Negotiated Rate |
$1,538.53 |
| Rate for Payer: Aetna Commercial |
$1,505.09
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,438.20
|
| Rate for Payer: Aetna Managed Medicare |
$468.25
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,087.01
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$836.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$802.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$886.33
|
| Rate for Payer: Cash Price |
$482.40
|
| Rate for Payer: Cigna Commercial |
$1,538.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$935.86
|
| Rate for Payer: Health EOS Commercial |
$1,488.36
|
| Rate for Payer: HFN Commercial |
$1,538.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,254.24
|
| Rate for Payer: Multiplan Commercial |
$1,337.86
|
| Rate for Payer: NAPHCARE Commercial |
$1,003.39
|
| Rate for Payer: Preferred Network Access Commercial |
$1,538.53
|
| Rate for Payer: Quartz Beloit One Network |
$819.44
|
| Rate for Payer: Quartz Commercial |
$1,087.01
|
| Rate for Payer: Quartz Medicare Advantage |
$1,003.39
|
| Rate for Payer: The Alliance Commercial |
$836.16
|
| Rate for Payer: WEA Trust Commercial |
$919.78
|
| Rate for Payer: WPS Commercial |
$1,238.64
|
|
|
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 |
$441.46 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Aetna Managed Medicare |
$441.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,024.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$788.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$756.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$882.31
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,182.48
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: NAPHCARE Commercial |
$945.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$1,024.82
|
| Rate for Payer: Quartz Medicare Advantage |
$945.98
|
| Rate for Payer: The Alliance Commercial |
$788.32
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$772.55 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$945.98
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$772.55 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$945.98
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$441.46 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Aetna Managed Medicare |
$441.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,024.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$788.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$756.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$882.31
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,182.48
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: NAPHCARE Commercial |
$945.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$1,024.82
|
| Rate for Payer: Quartz Medicare Advantage |
$945.98
|
| Rate for Payer: The Alliance Commercial |
$788.32
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$441.46 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Aetna Managed Medicare |
$441.46
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,024.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$788.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$756.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$882.31
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,182.48
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: NAPHCARE Commercial |
$945.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$1,024.82
|
| Rate for Payer: Quartz Medicare Advantage |
$945.98
|
| Rate for Payer: The Alliance Commercial |
$788.32
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$772.55 |
| Max. Negotiated Rate |
$1,450.51 |
| Rate for Payer: Aetna Commercial |
$1,418.98
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,355.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$835.62
|
| Rate for Payer: Cash Price |
$454.80
|
| Rate for Payer: Cigna Commercial |
$1,450.51
|
| Rate for Payer: Health EOS Commercial |
$1,403.21
|
| Rate for Payer: HFN Commercial |
$1,450.51
|
| Rate for Payer: Multiplan Commercial |
$1,261.31
|
| Rate for Payer: Preferred Network Access Commercial |
$1,450.51
|
| Rate for Payer: Quartz Beloit One Network |
$772.55
|
| Rate for Payer: Quartz Commercial |
$945.98
|
| Rate for Payer: WEA Trust Commercial |
$867.15
|
| Rate for Payer: WPS Commercial |
$1,167.77
|
|
|
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 |
$513.68 |
| Max. Negotiated Rate |
$1,687.80 |
| Rate for Payer: Aetna Commercial |
$1,651.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,577.72
|
| Rate for Payer: Aetna Managed Medicare |
$513.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,192.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$917.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$880.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$972.32
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cigna Commercial |
$1,687.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,026.65
|
| Rate for Payer: Health EOS Commercial |
$1,632.76
|
| Rate for Payer: HFN Commercial |
$1,687.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,375.92
|
| Rate for Payer: Multiplan Commercial |
$1,467.65
|
| Rate for Payer: NAPHCARE Commercial |
$1,100.74
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.80
|
| Rate for Payer: Quartz Beloit One Network |
$898.93
|
| Rate for Payer: Quartz Commercial |
$1,192.46
|
| Rate for Payer: Quartz Medicare Advantage |
$1,100.74
|
| Rate for Payer: The Alliance Commercial |
$917.28
|
| Rate for Payer: WEA Trust Commercial |
$1,009.01
|
| Rate for Payer: WPS Commercial |
$1,358.81
|
|
|
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 |
$898.93 |
| Max. Negotiated Rate |
$1,687.80 |
| Rate for Payer: Aetna Commercial |
$1,651.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,577.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$972.32
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cigna Commercial |
$1,687.80
|
| Rate for Payer: Health EOS Commercial |
$1,632.76
|
| Rate for Payer: HFN Commercial |
$1,687.80
|
| Rate for Payer: Multiplan Commercial |
$1,467.65
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.80
|
| Rate for Payer: Quartz Beloit One Network |
$898.93
|
| Rate for Payer: Quartz Commercial |
$1,100.74
|
| Rate for Payer: WEA Trust Commercial |
$1,009.01
|
| Rate for Payer: WPS Commercial |
$1,358.81
|
|
|
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 |
$533.48 |
| Max. Negotiated Rate |
$1,752.86 |
| Rate for Payer: Aetna Commercial |
$1,714.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,638.54
|
| Rate for Payer: Aetna Managed Medicare |
$533.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,238.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$914.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.80
|
| Rate for Payer: Cash Price |
$549.60
|
| Rate for Payer: Cigna Commercial |
$1,752.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,066.22
|
| Rate for Payer: Health EOS Commercial |
$1,695.70
|
| Rate for Payer: HFN Commercial |
$1,752.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.96
|
| Rate for Payer: Multiplan Commercial |
$1,524.22
|
| Rate for Payer: NAPHCARE Commercial |
$1,143.17
|
| Rate for Payer: Preferred Network Access Commercial |
$1,752.86
|
| Rate for Payer: Quartz Beloit One Network |
$933.59
|
| Rate for Payer: Quartz Commercial |
$1,238.43
|
| Rate for Payer: Quartz Medicare Advantage |
$1,143.17
|
| Rate for Payer: The Alliance Commercial |
$952.64
|
| Rate for Payer: WEA Trust Commercial |
$1,047.90
|
| Rate for Payer: WPS Commercial |
$1,411.19
|
|
|
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 |
$933.59 |
| Max. Negotiated Rate |
$1,752.86 |
| Rate for Payer: Aetna Commercial |
$1,714.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,638.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.80
|
| Rate for Payer: Cash Price |
$549.60
|
| Rate for Payer: Cigna Commercial |
$1,752.86
|
| Rate for Payer: Health EOS Commercial |
$1,695.70
|
| Rate for Payer: HFN Commercial |
$1,752.86
|
| Rate for Payer: Multiplan Commercial |
$1,524.22
|
| Rate for Payer: Preferred Network Access Commercial |
$1,752.86
|
| Rate for Payer: Quartz Beloit One Network |
$933.59
|
| Rate for Payer: Quartz Commercial |
$1,143.17
|
| Rate for Payer: WEA Trust Commercial |
$1,047.90
|
| Rate for Payer: WPS Commercial |
$1,411.19
|
|
|
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
|
$13,799.89
|
|
|
Service Code
|
CPT 50953
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,709.65 |
| Max. Negotiated Rate |
$13,799.89 |
| Rate for Payer: Aetna Managed Medicare |
$3,709.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$10,303.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,364.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$7,944.56
|
| Rate for Payer: Anthem Medicare Advantage |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$3,709.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$3,709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$3,709.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$3,709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,799.89
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$3,709.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$3,709.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$3,709.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$3,709.65
|
| Rate for Payer: NAPHCARE Commercial |
$5,564.47
|
| Rate for Payer: Quartz Medicare Advantage |
$3,709.65
|
| Rate for Payer: The Alliance Commercial |
$6,306.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$3,709.65
|
| Rate for Payer: United Healthcare PPO |
$4,267.12
|
| Rate for Payer: Wellcare Medicare |
$3,709.65
|
|
|
URETERECTOMY, TOTAL
|
Facility
|
IP
|
$7,912.00
|
|
| Hospital Charge Code |
2960468
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,031.96 |
| Max. Negotiated Rate |
$7,570.20 |
| Rate for Payer: Aetna Commercial |
$7,405.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,076.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,361.09
|
| Rate for Payer: Cash Price |
$2,373.60
|
| Rate for Payer: Cigna Commercial |
$7,570.20
|
| Rate for Payer: Health EOS Commercial |
$7,323.35
|
| Rate for Payer: HFN Commercial |
$7,570.20
|
| Rate for Payer: Multiplan Commercial |
$6,582.78
|
| Rate for Payer: Preferred Network Access Commercial |
$7,570.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,031.96
|
| Rate for Payer: Quartz Commercial |
$4,937.09
|
| Rate for Payer: WEA Trust Commercial |
$4,525.66
|
| Rate for Payer: WPS Commercial |
$6,094.61
|
|
|
URETERECTOMY, TOTAL
|
Facility
|
OP
|
$7,912.00
|
|
| Hospital Charge Code |
2960468
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,303.97 |
| Max. Negotiated Rate |
$7,570.20 |
| Rate for Payer: Aetna Commercial |
$7,405.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,076.49
|
| Rate for Payer: Aetna Managed Medicare |
$2,303.97
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,348.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,114.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,949.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,361.09
|
| Rate for Payer: Cash Price |
$2,373.60
|
| Rate for Payer: Cigna Commercial |
$7,570.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,604.78
|
| Rate for Payer: Health EOS Commercial |
$7,323.35
|
| Rate for Payer: HFN Commercial |
$7,570.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,171.36
|
| Rate for Payer: Multiplan Commercial |
$6,582.78
|
| Rate for Payer: NAPHCARE Commercial |
$4,937.09
|
| Rate for Payer: Preferred Network Access Commercial |
$7,570.20
|
| Rate for Payer: Quartz Beloit One Network |
$4,031.96
|
| Rate for Payer: Quartz Commercial |
$5,348.51
|
| Rate for Payer: Quartz Medicare Advantage |
$4,937.09
|
| Rate for Payer: The Alliance Commercial |
$4,114.24
|
| Rate for Payer: WEA Trust Commercial |
$4,525.66
|
| Rate for Payer: WPS Commercial |
$6,094.61
|
|
