|
Visipaque 320 100ml
|
Facility
|
IP
|
$489.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$239.61 |
| Max. Negotiated Rate |
$449.88 |
| Rate for Payer: Aetna Commercial |
$440.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.17
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$449.88
|
| Rate for Payer: Health EOS Commercial |
$435.21
|
| Rate for Payer: HFN Commercial |
$449.88
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: NAPHCARE Commercial |
$293.40
|
| Rate for Payer: Preferred Network Access Commercial |
$449.88
|
| Rate for Payer: Quartz Beloit One Network |
$239.61
|
| Rate for Payer: Quartz Commercial |
$293.40
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$362.20
|
|
|
Visipaque 320 100ml
|
Professional
|
Both
|
$489.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
1158860
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$464.55 |
| Rate for Payer: Aetna Commercial |
$464.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$464.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$444.99
|
| Rate for Payer: HFN Commercial |
$464.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: Preferred Network Access Commercial |
$464.55
|
| Rate for Payer: Quartz Beloit One Network |
$215.16
|
| Rate for Payer: Quartz Commercial |
$278.73
|
| Rate for Payer: The Alliance Commercial |
$244.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Visipaque 320 150ml
|
Facility
|
OP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$2,116.00 |
| Rate for Payer: Aetna Commercial |
$476.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Aetna Managed Medicare |
$148.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$343.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$264.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$253.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.37
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$486.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$470.81
|
| Rate for Payer: HFN Commercial |
$486.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$396.75
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: NAPHCARE Commercial |
$317.40
|
| Rate for Payer: Preferred Network Access Commercial |
$486.68
|
| Rate for Payer: Quartz Beloit One Network |
$259.21
|
| Rate for Payer: Quartz Commercial |
$343.85
|
| Rate for Payer: Quartz Medicare Advantage |
$317.40
|
| Rate for Payer: The Alliance Commercial |
$2,116.00
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Visipaque 320 150ml
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$259.21 |
| Max. Negotiated Rate |
$486.68 |
| Rate for Payer: Aetna Commercial |
$476.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.37
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$486.68
|
| Rate for Payer: Health EOS Commercial |
$470.81
|
| Rate for Payer: HFN Commercial |
$486.68
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: NAPHCARE Commercial |
$317.40
|
| Rate for Payer: Preferred Network Access Commercial |
$486.68
|
| Rate for Payer: Quartz Beloit One Network |
$259.21
|
| Rate for Payer: Quartz Commercial |
$317.40
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$391.83
|
|
|
Visipaque 320 150ml
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2944293
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$502.55 |
| Rate for Payer: Aetna Commercial |
$502.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$454.94
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$502.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$481.39
|
| Rate for Payer: HFN Commercial |
$502.55
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$423.20
|
| Rate for Payer: Preferred Network Access Commercial |
$502.55
|
| Rate for Payer: Quartz Beloit One Network |
$232.76
|
| Rate for Payer: Quartz Commercial |
$301.53
|
| Rate for Payer: The Alliance Commercial |
$264.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$290.95
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Visipaque 50cc
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444866
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$476.00 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Aetna Managed Medicare |
$33.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$77.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$57.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.25
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$77.35
|
| Rate for Payer: Quartz Medicare Advantage |
$71.40
|
| Rate for Payer: The Alliance Commercial |
$476.00
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Visipaque 50cc
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444866
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$109.48 |
| Rate for Payer: Aetna Commercial |
$107.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.07
|
| Rate for Payer: Cash Price |
$35.70
|
| Rate for Payer: Cigna Commercial |
$109.48
|
| Rate for Payer: Health EOS Commercial |
$105.91
|
| Rate for Payer: HFN Commercial |
$109.48
|
| Rate for Payer: Multiplan Commercial |
$95.20
|
| Rate for Payer: NAPHCARE Commercial |
$71.40
|
| Rate for Payer: Preferred Network Access Commercial |
$109.48
|
| Rate for Payer: Quartz Beloit One Network |
$58.31
|
| Rate for Payer: Quartz Commercial |
$71.40
|
| Rate for Payer: WEA Trust Commercial |
$65.45
|
| Rate for Payer: WPS Commercial |
$88.14
|
|
|
Visipaque 50cc
|
Professional
|
Both
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$114.95 |
| Rate for Payer: Aetna Commercial |
$114.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$114.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$110.11
|
| Rate for Payer: HFN Commercial |
$114.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.16
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: Preferred Network Access Commercial |
$114.95
|
| Rate for Payer: Quartz Beloit One Network |
$53.24
|
| Rate for Payer: Quartz Commercial |
$68.97
|
| Rate for Payer: The Alliance Commercial |
$60.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.12
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
Visipaque 50cc
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.29 |
| Max. Negotiated Rate |
$111.32 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$72.60
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$89.62
|
|
|
Visipaque 50cc
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$484.00 |
| Rate for Payer: Aetna Commercial |
$108.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$104.06
|
| Rate for Payer: Aetna Managed Medicare |
$33.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$78.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$60.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$64.13
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cash Price |
$36.30
|
| Rate for Payer: Cigna Commercial |
$111.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.18
|
| Rate for Payer: Health EOS Commercial |
$107.69
|
| Rate for Payer: HFN Commercial |
$111.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$90.75
|
| Rate for Payer: Multiplan Commercial |
$96.80
|
| Rate for Payer: NAPHCARE Commercial |
$72.60
|
| Rate for Payer: Preferred Network Access Commercial |
$111.32
|
| Rate for Payer: Quartz Beloit One Network |
$59.29
|
| Rate for Payer: Quartz Commercial |
$78.65
|
| Rate for Payer: Quartz Medicare Advantage |
$72.60
|
| Rate for Payer: The Alliance Commercial |
$484.00
|
| Rate for Payer: WEA Trust Commercial |
$66.55
|
| Rate for Payer: WPS Commercial |
$0.34
|
|
|
VisiPro 7mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548984
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 7mm x 27mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2548986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Professional
|
Both
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,346.76 |
| Max. Negotiated Rate |
$9,385.05 |
| Rate for Payer: Aetna Commercial |
$9,385.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,385.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4,939.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,927.40
|
| Rate for Payer: Health EOS Commercial |
$8,989.89
|
| Rate for Payer: HFN Commercial |
$9,385.05
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: Preferred Network Access Commercial |
$9,385.05
|
| Rate for Payer: Quartz Beloit One Network |
$4,346.76
|
| Rate for Payer: Quartz Commercial |
$5,631.03
|
| Rate for Payer: The Alliance Commercial |
$4,939.50
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
IP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,840.71 |
| Max. Negotiated Rate |
$9,088.68 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$5,927.40
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
VisiPro 8mm x 17mm
|
Facility
|
OP
|
$9,879.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
2549064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,766.12 |
| Max. Negotiated Rate |
$39,516.00 |
| Rate for Payer: Aetna Commercial |
$8,891.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,495.94
|
| Rate for Payer: Aetna Managed Medicare |
$2,766.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,421.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,939.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,741.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,235.87
|
| Rate for Payer: Cash Price |
$2,963.70
|
| Rate for Payer: Cigna Commercial |
$9,088.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,528.29
|
| Rate for Payer: Health EOS Commercial |
$8,792.31
|
| Rate for Payer: HFN Commercial |
$9,088.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,409.25
|
| Rate for Payer: Multiplan Commercial |
$7,903.20
|
| Rate for Payer: NAPHCARE Commercial |
$5,927.40
|
| Rate for Payer: Preferred Network Access Commercial |
$9,088.68
|
| Rate for Payer: Quartz Beloit One Network |
$4,840.71
|
| Rate for Payer: Quartz Commercial |
$6,421.35
|
| Rate for Payer: Quartz Medicare Advantage |
$5,927.40
|
| Rate for Payer: The Alliance Commercial |
$39,516.00
|
| Rate for Payer: WEA Trust Commercial |
$5,433.45
|
| Rate for Payer: WPS Commercial |
$7,317.38
|
|
|
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 |
$123.97 |
| Max. Negotiated Rate |
$232.76 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$151.80
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$151.80
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
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 |
$88.10 |
| Max. Negotiated Rate |
$352.40 |
| Rate for Payer: Aetna Commercial |
$227.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.58
|
| Rate for Payer: Aetna Managed Medicare |
$88.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.44
|
| Rate for Payer: Anthem Medicare Advantage |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$134.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$88.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$88.10
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cash Price |
$75.90
|
| Rate for Payer: Cigna Commercial |
$232.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$88.10
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$141.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$88.10
|
| Rate for Payer: Health EOS Commercial |
$225.17
|
| Rate for Payer: HFN Commercial |
$232.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$327.73
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.10
|
| Rate for Payer: Independent Care Health Plan Medicare |
$88.10
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$88.10
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$88.10
|
| Rate for Payer: Multiplan Commercial |
$202.40
|
| Rate for Payer: NAPHCARE Commercial |
$132.15
|
| Rate for Payer: Preferred Network Access Commercial |
$232.76
|
| Rate for Payer: Quartz Beloit One Network |
$123.97
|
| Rate for Payer: Quartz Commercial |
$164.45
|
| Rate for Payer: Quartz Medicare Advantage |
$88.10
|
| Rate for Payer: The Alliance Commercial |
$352.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$88.10
|
| Rate for Payer: WEA Trust Commercial |
$139.15
|
| Rate for Payer: Wellcare Medicare |
$88.10
|
| Rate for Payer: WPS Commercial |
$187.40
|
|
|
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 |
$22.44 |
| Max. Negotiated Rate |
$88.71 |
| Rate for Payer: Aetna Commercial |
$48.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.86
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cigna Commercial |
$48.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.60
|
| Rate for Payer: Health EOS Commercial |
$46.41
|
| Rate for Payer: HFN Commercial |
$48.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.71
|
| Rate for Payer: Multiplan Commercial |
$40.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.45
|
| Rate for Payer: Quartz Beloit One Network |
$22.44
|
| Rate for Payer: Quartz Commercial |
$29.07
|
| Rate for Payer: The Alliance Commercial |
$25.50
|
| Rate for Payer: WEA Trust Commercial |
$28.05
|
| Rate for Payer: WPS Commercial |
$37.78
|
|
|
VISI-WIPE 581047
|
Facility
|
IP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.16 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$50.40
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
VISI-WIPE 581047
|
Facility
|
OP
|
$84.00
|
|
| Hospital Charge Code |
2964800
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.52 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$75.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.24
|
| Rate for Payer: Aetna Managed Medicare |
$23.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.52
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cigna Commercial |
$77.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.01
|
| Rate for Payer: Health EOS Commercial |
$74.76
|
| Rate for Payer: HFN Commercial |
$77.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.00
|
| Rate for Payer: Multiplan Commercial |
$67.20
|
| Rate for Payer: NAPHCARE Commercial |
$50.40
|
| Rate for Payer: Preferred Network Access Commercial |
$77.28
|
| Rate for Payer: Quartz Beloit One Network |
$41.16
|
| Rate for Payer: Quartz Commercial |
$54.60
|
| Rate for Payer: Quartz Medicare Advantage |
$50.40
|
| Rate for Payer: The Alliance Commercial |
$336.00
|
| Rate for Payer: WEA Trust Commercial |
$46.20
|
| Rate for Payer: WPS Commercial |
$62.22
|
|
|
Vistaril 25 mg Charge
|
Facility
|
OP
|
$7.00
|
|
|
Service Code
|
HCPCS J3410
|
| Hospital Charge Code |
2958853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$6.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6.02
|
| Rate for Payer: Aetna Managed Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$6.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.35
|
| Rate for Payer: Health EOS Commercial |
$6.23
|
| Rate for Payer: HFN Commercial |
$6.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5.25
|
| Rate for Payer: Multiplan Commercial |
$5.60
|
| Rate for Payer: NAPHCARE Commercial |
$4.20
|
| Rate for Payer: Preferred Network Access Commercial |
$6.44
|
| Rate for Payer: Quartz Beloit One Network |
$3.43
|
| Rate for Payer: Quartz Commercial |
$4.55
|
| Rate for Payer: Quartz Medicare Advantage |
$4.20
|
| Rate for Payer: The Alliance Commercial |
$28.00
|
| Rate for Payer: WEA Trust Commercial |
$3.85
|
| Rate for Payer: WPS Commercial |
$34.67
|
|
