|
Visipaque 270 150ml
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
2944291
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Aetna Managed Medicare |
$154.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$357.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$275.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$264.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.53
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$412.62
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: NAPHCARE Commercial |
$330.10
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$357.60
|
| Rate for Payer: Quartz Medicare Advantage |
$330.10
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
|
Visipaque 270 150ml
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
2944291
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$522.65 |
| Rate for Payer: Aetna Commercial |
$522.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Aetna Managed Medicare |
$0.42
|
| Rate for Payer: Anthem Medicare Advantage |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.42
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$522.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.40
|
| Rate for Payer: Health EOS Commercial |
$500.65
|
| Rate for Payer: HFN Commercial |
$522.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: NAPHCARE Commercial |
$0.62
|
| Rate for Payer: Preferred Network Access Commercial |
$522.65
|
| Rate for Payer: Quartz Beloit One Network |
$242.07
|
| Rate for Payer: Quartz Commercial |
$313.59
|
| Rate for Payer: Quartz Medicare Advantage |
$0.42
|
| Rate for Payer: The Alliance Commercial |
$1.14
|
| Rate for Payer: United Healthcare Medicaid |
$0.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.42
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$1.01
|
|
|
Visipaque 320 100ml
|
Facility
|
OP
|
$489.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$467.88 |
| Rate for Payer: Aetna Commercial |
$457.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.36
|
| Rate for Payer: Aetna Managed Medicare |
$142.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$330.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$254.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$244.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.54
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$467.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$452.62
|
| Rate for Payer: HFN Commercial |
$467.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$381.42
|
| Rate for Payer: Multiplan Commercial |
$406.85
|
| Rate for Payer: NAPHCARE Commercial |
$305.14
|
| Rate for Payer: Preferred Network Access Commercial |
$467.88
|
| Rate for Payer: Quartz Beloit One Network |
$249.19
|
| Rate for Payer: Quartz Commercial |
$330.56
|
| Rate for Payer: Quartz Medicare Advantage |
$305.14
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$279.71
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 320 100ml
|
Facility
|
IP
|
$489.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$249.19 |
| Max. Negotiated Rate |
$467.88 |
| Rate for Payer: Aetna Commercial |
$457.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.54
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$467.88
|
| Rate for Payer: Health EOS Commercial |
$452.62
|
| Rate for Payer: HFN Commercial |
$467.88
|
| Rate for Payer: Multiplan Commercial |
$406.85
|
| Rate for Payer: Preferred Network Access Commercial |
$467.88
|
| Rate for Payer: Quartz Beloit One Network |
$249.19
|
| Rate for Payer: Quartz Commercial |
$305.14
|
| Rate for Payer: WEA Trust Commercial |
$279.71
|
| Rate for Payer: WPS Commercial |
$376.68
|
|
|
Visipaque 320 100ml
|
Professional
|
Both
|
$489.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$483.13 |
| Rate for Payer: Aetna Commercial |
$483.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.36
|
| 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 |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$483.13
|
| 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 |
$462.79
|
| Rate for Payer: HFN Commercial |
$483.13
|
| 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 |
$406.85
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$483.13
|
| Rate for Payer: Quartz Beloit One Network |
$223.77
|
| Rate for Payer: Quartz Commercial |
$289.88
|
| 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 |
$279.71
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 320 150ml
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$522.65 |
| Rate for Payer: Aetna Commercial |
$522.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| 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 |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$522.65
|
| 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 |
$500.65
|
| Rate for Payer: HFN Commercial |
$522.65
|
| 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 |
$440.13
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$522.65
|
| Rate for Payer: Quartz Beloit One Network |
$242.07
|
| Rate for Payer: Quartz Commercial |
$313.59
|
| 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 |
$302.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 320 150ml
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Aetna Managed Medicare |
$154.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$357.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$275.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$264.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$412.62
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: NAPHCARE Commercial |
$330.10
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$357.60
|
| Rate for Payer: Quartz Medicare Advantage |
$330.10
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 320 150ml
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$269.58 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$330.10
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
|
Visipaque 50cc
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444866
|
|
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
|
|
|
Visipaque 50cc
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
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
|
|
|
Visipaque 50cc
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444866
|
|
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
|
|
|
Visipaque 50cc
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
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
|
|
|
Visipaque 50cc
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
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
|
|
|
VisiPro 7mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,520.63 |
| Max. Negotiated Rate |
$9,760.45 |
| Rate for Payer: Aetna Commercial |
$9,760.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,760.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,137.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,164.50
|
| Rate for Payer: Health EOS Commercial |
$9,349.49
|
| Rate for Payer: HFN Commercial |
$9,760.45
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,760.45
|
| Rate for Payer: Quartz Beloit One Network |
$4,520.63
|
| Rate for Payer: Quartz Commercial |
$5,856.27
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,876.76 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Aetna Managed Medicare |
$2,876.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,678.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,137.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,931.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,749.58
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,705.62
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: NAPHCARE Commercial |
$6,164.50
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,678.20
|
| Rate for Payer: Quartz Medicare Advantage |
$6,164.50
|
| Rate for Payer: The Alliance Commercial |
$5,137.08
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,034.34 |
| Max. Negotiated Rate |
$9,452.23 |
| Rate for Payer: Aetna Commercial |
$9,246.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,835.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,445.30
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,452.23
|
| Rate for Payer: Health EOS Commercial |
$9,144.00
|
| Rate for Payer: HFN Commercial |
$9,452.23
|
| Rate for Payer: Multiplan Commercial |
$8,219.33
|
| Rate for Payer: Preferred Network Access Commercial |
$9,452.23
|
| Rate for Payer: Quartz Beloit One Network |
$5,034.34
|
| Rate for Payer: Quartz Commercial |
$6,164.50
|
| Rate for Payer: WEA Trust Commercial |
$5,650.79
|
| Rate for Payer: WPS Commercial |
$7,609.79
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$106.91 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Aetna Managed Medicare |
$106.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$171.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$131.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$126.30
|
| Rate for Payer: Anthem Medicare Advantage |
$106.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$106.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$106.91
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$106.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$147.25
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$106.91
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$397.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$106.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$106.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$106.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$106.91
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: NAPHCARE Commercial |
$160.37
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$171.03
|
| Rate for Payer: Quartz Medicare Advantage |
$106.91
|
| Rate for Payer: The Alliance Commercial |
$427.65
|
| Rate for Payer: United Healthcare Medicare Advantage |
$106.91
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: Wellcare Medicare |
$106.91
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Professional
|
Both
|
$51.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.38 |
| Max. Negotiated Rate |
$92.26 |
| Rate for Payer: Aetna Commercial |
$50.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.61
|
| Rate for Payer: Aetna Managed Medicare |
$22.38
|
| Rate for Payer: Anthem Medicare Advantage |
$22.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$22.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$22.38
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$50.39
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$26.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$22.38
|
| Rate for Payer: Health EOS Commercial |
$48.27
|
| Rate for Payer: HFN Commercial |
$50.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$92.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$22.38
|
| Rate for Payer: Multiplan Commercial |
$42.43
|
| Rate for Payer: NAPHCARE Commercial |
$33.57
|
| Rate for Payer: Preferred Network Access Commercial |
$50.39
|
| Rate for Payer: Quartz Beloit One Network |
$23.34
|
| Rate for Payer: Quartz Commercial |
$30.23
|
| Rate for Payer: Quartz Medicare Advantage |
$22.38
|
| Rate for Payer: The Alliance Commercial |
$61.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$22.38
|
| Rate for Payer: WEA Trust Commercial |
$29.17
|
| Rate for Payer: WPS Commercial |
$39.17
|
|
|
VISIT TO DETERM LDCT ELIG - G0296
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
5783629
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$128.93 |
| Max. Negotiated Rate |
$242.07 |
| Rate for Payer: Aetna Commercial |
$236.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$226.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$139.45
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$242.07
|
| Rate for Payer: Health EOS Commercial |
$234.18
|
| Rate for Payer: HFN Commercial |
$242.07
|
| Rate for Payer: Multiplan Commercial |
$210.50
|
| Rate for Payer: Preferred Network Access Commercial |
$242.07
|
| Rate for Payer: Quartz Beloit One Network |
$128.93
|
| Rate for Payer: Quartz Commercial |
$157.87
|
| Rate for Payer: WEA Trust Commercial |
$144.72
|
| Rate for Payer: WPS Commercial |
$194.89
|
|
