|
Cysticercus Antibody
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
3449632
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$242.06 |
| Max. Negotiated Rate |
$454.48 |
| Rate for Payer: Aetna Commercial |
$444.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$424.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$261.82
|
| Rate for Payer: Cash Price |
$142.50
|
| Rate for Payer: Cigna Commercial |
$454.48
|
| Rate for Payer: Health EOS Commercial |
$439.66
|
| Rate for Payer: HFN Commercial |
$454.48
|
| Rate for Payer: Multiplan Commercial |
$395.20
|
| Rate for Payer: Preferred Network Access Commercial |
$454.48
|
| Rate for Payer: Quartz Beloit One Network |
$242.06
|
| Rate for Payer: Quartz Commercial |
$296.40
|
| Rate for Payer: WEA Trust Commercial |
$271.70
|
| Rate for Payer: WPS Commercial |
$365.89
|
|
|
Cysticercus Antibody, ELISA, CSF
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
3949336
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$127.25 |
| Rate for Payer: Aetna Commercial |
$124.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Aetna Managed Medicare |
$13.53
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$50.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22.46
|
| Rate for Payer: Anthem Medicare Advantage |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.53
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$127.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$13.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.41
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$13.53
|
| Rate for Payer: Health EOS Commercial |
$123.10
|
| Rate for Payer: HFN Commercial |
$127.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.33
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$13.53
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$13.53
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$13.53
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: NAPHCARE Commercial |
$20.30
|
| Rate for Payer: Preferred Network Access Commercial |
$127.25
|
| Rate for Payer: Quartz Beloit One Network |
$67.78
|
| Rate for Payer: Quartz Commercial |
$89.91
|
| Rate for Payer: Quartz Medicare Advantage |
$13.53
|
| Rate for Payer: The Alliance Commercial |
$54.12
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.53
|
| Rate for Payer: United Healthcare PPO |
$103.74
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: Wellcare Medicare |
$13.53
|
| Rate for Payer: WPS Commercial |
$102.45
|
|
|
Cysticercus Antibody, ELISA, CSF
|
Professional
|
Both
|
$133.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
3949336
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$131.40 |
| Rate for Payer: Aetna Commercial |
$131.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Aetna Managed Medicare |
$13.53
|
| Rate for Payer: Anthem Medicare Advantage |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$13.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$13.53
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$131.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.53
|
| Rate for Payer: Health EOS Commercial |
$125.87
|
| Rate for Payer: HFN Commercial |
$131.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.77
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$13.53
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: NAPHCARE Commercial |
$20.30
|
| Rate for Payer: Preferred Network Access Commercial |
$131.40
|
| Rate for Payer: Quartz Beloit One Network |
$60.86
|
| Rate for Payer: Quartz Commercial |
$78.84
|
| Rate for Payer: Quartz Medicare Advantage |
$13.53
|
| Rate for Payer: The Alliance Commercial |
$53.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$13.53
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: WPS Commercial |
$59.53
|
|
|
Cysticercus Antibody, ELISA, CSF
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
3949336
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$127.25 |
| Rate for Payer: Aetna Commercial |
$124.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.31
|
| Rate for Payer: Cash Price |
$39.90
|
| Rate for Payer: Cigna Commercial |
$127.25
|
| Rate for Payer: Health EOS Commercial |
$123.10
|
| Rate for Payer: HFN Commercial |
$127.25
|
| Rate for Payer: Multiplan Commercial |
$110.66
|
| Rate for Payer: Preferred Network Access Commercial |
$127.25
|
| Rate for Payer: Quartz Beloit One Network |
$67.78
|
| Rate for Payer: Quartz Commercial |
$82.99
|
| Rate for Payer: WEA Trust Commercial |
$76.08
|
| Rate for Payer: WPS Commercial |
$102.45
|
|
|
Cystic Fibrosis Interpretation
|
Facility
|
IP
|
$8.00
|
|
| Hospital Charge Code |
2798799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$4.99
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
Cystic Fibrosis Interpretation
|
Professional
|
Both
|
$8.00
|
|
| Hospital Charge Code |
2798799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.66 |
| Max. Negotiated Rate |
$7.90 |
| Rate for Payer: Aetna Commercial |
$7.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$4.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.99
|
| Rate for Payer: Health EOS Commercial |
$7.57
|
| Rate for Payer: HFN Commercial |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: Preferred Network Access Commercial |
$7.90
|
| Rate for Payer: Quartz Beloit One Network |
$3.66
|
| Rate for Payer: Quartz Commercial |
$4.74
|
| Rate for Payer: The Alliance Commercial |
$4.16
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
Cystic Fibrosis Interpretation
|
Facility
|
OP
|
$8.00
|
|
| Hospital Charge Code |
2798799
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.49
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7.16
|
| Rate for Payer: Aetna Managed Medicare |
$2.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.41
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$7.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4.66
|
| Rate for Payer: Health EOS Commercial |
$7.40
|
| Rate for Payer: HFN Commercial |
$7.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6.24
|
| Rate for Payer: Multiplan Commercial |
$6.66
|
| Rate for Payer: NAPHCARE Commercial |
$4.99
|
| Rate for Payer: Preferred Network Access Commercial |
$7.65
|
| Rate for Payer: Quartz Beloit One Network |
$4.08
|
| Rate for Payer: Quartz Commercial |
$5.41
|
| Rate for Payer: Quartz Medicare Advantage |
$4.99
|
| Rate for Payer: The Alliance Commercial |
$4.16
|
| Rate for Payer: United Healthcare PPO |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$4.58
|
| Rate for Payer: WPS Commercial |
$6.16
|
|
|
Cystic Fibrosis Mutation DNA Analysis
|
Facility
|
OP
|
$580.00
|
|
|
Service Code
|
CPT 81220
|
| Hospital Charge Code |
977920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$295.57 |
| Max. Negotiated Rate |
$2,315.46 |
| Rate for Payer: Aetna Commercial |
$542.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$518.75
|
| Rate for Payer: Aetna Managed Medicare |
$578.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,170.74
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,013.01
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$960.91
|
| Rate for Payer: Anthem Medicare Advantage |
$578.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$578.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$578.86
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$554.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$578.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$337.56
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$578.86
|
| Rate for Payer: Health EOS Commercial |
$536.85
|
| Rate for Payer: HFN Commercial |
$554.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,153.37
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$578.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$578.86
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$578.86
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$578.86
|
| Rate for Payer: Multiplan Commercial |
$482.56
|
| Rate for Payer: NAPHCARE Commercial |
$868.30
|
| Rate for Payer: Preferred Network Access Commercial |
$554.94
|
| Rate for Payer: Quartz Beloit One Network |
$295.57
|
| Rate for Payer: Quartz Commercial |
$392.08
|
| Rate for Payer: Quartz Medicare Advantage |
$578.86
|
| Rate for Payer: The Alliance Commercial |
$2,315.46
|
| Rate for Payer: United Healthcare Medicare Advantage |
$578.86
|
| Rate for Payer: United Healthcare PPO |
$452.40
|
| Rate for Payer: WEA Trust Commercial |
$331.76
|
| Rate for Payer: Wellcare Medicare |
$578.86
|
| Rate for Payer: WPS Commercial |
$446.77
|
|
|
Cystic Fibrosis Mutation DNA Analysis
|
Facility
|
IP
|
$580.00
|
|
|
Service Code
|
CPT 81220
|
| Hospital Charge Code |
977920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$295.57 |
| Max. Negotiated Rate |
$554.94 |
| Rate for Payer: Aetna Commercial |
$542.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$518.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.70
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$554.94
|
| Rate for Payer: Health EOS Commercial |
$536.85
|
| Rate for Payer: HFN Commercial |
$554.94
|
| Rate for Payer: Multiplan Commercial |
$482.56
|
| Rate for Payer: Preferred Network Access Commercial |
$554.94
|
| Rate for Payer: Quartz Beloit One Network |
$295.57
|
| Rate for Payer: Quartz Commercial |
$361.92
|
| Rate for Payer: WEA Trust Commercial |
$331.76
|
| Rate for Payer: WPS Commercial |
$446.77
|
|
|
Cystic Fibrosis Mutation DNA Analysis
|
Professional
|
Both
|
$580.00
|
|
|
Service Code
|
CPT 81220
|
| Hospital Charge Code |
977920
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$265.41 |
| Max. Negotiated Rate |
$2,547.00 |
| Rate for Payer: Aetna Commercial |
$573.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$518.75
|
| Rate for Payer: Aetna Managed Medicare |
$578.86
|
| Rate for Payer: Anthem Medicare Advantage |
$578.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$578.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$578.86
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cash Price |
$174.00
|
| Rate for Payer: Cigna Commercial |
$573.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$301.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$578.86
|
| Rate for Payer: Health EOS Commercial |
$548.91
|
| Rate for Payer: HFN Commercial |
$573.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,043.39
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,043.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$578.86
|
| Rate for Payer: Multiplan Commercial |
$482.56
|
| Rate for Payer: NAPHCARE Commercial |
$868.30
|
| Rate for Payer: Preferred Network Access Commercial |
$573.04
|
| Rate for Payer: Quartz Beloit One Network |
$265.41
|
| Rate for Payer: Quartz Commercial |
$343.82
|
| Rate for Payer: Quartz Medicare Advantage |
$578.86
|
| Rate for Payer: The Alliance Commercial |
$2,286.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$578.86
|
| Rate for Payer: WEA Trust Commercial |
$331.76
|
| Rate for Payer: WPS Commercial |
$2,547.00
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
OP
|
$127.10
|
|
|
Service Code
|
EAPG 00570
|
| Min. Negotiated Rate |
$122.21 |
| Max. Negotiated Rate |
$127.10 |
| Rate for Payer: Anthem Medicaid |
$122.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$122.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$122.21
|
| Rate for Payer: Dean Health Medicaid |
$122.21
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$122.21
|
| Rate for Payer: Managed Health Services Medicaid |
$127.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.21
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$122.21
|
| Rate for Payer: United Healthcare Medicaid |
$122.21
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$15,519.91
|
|
|
Service Code
|
APR-DRG 1312
|
| Min. Negotiated Rate |
$13,785.75 |
| Max. Negotiated Rate |
$15,519.91 |
| Rate for Payer: Anthem Medicaid |
$14,861.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$14,861.17
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$14,861.17
|
| Rate for Payer: Dean Health Medicaid |
$14,861.17
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13,785.75
|
| Rate for Payer: Managed Health Services Medicaid |
$15,519.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,861.17
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$14,861.17
|
| Rate for Payer: United Healthcare Medicaid |
$14,861.17
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$9,469.77
|
|
|
Service Code
|
APR-DRG 1311
|
| Min. Negotiated Rate |
$8,411.64 |
| Max. Negotiated Rate |
$9,469.77 |
| Rate for Payer: Anthem Medicaid |
$9,067.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$9,067.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,067.83
|
| Rate for Payer: Dean Health Medicaid |
$9,067.83
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$8,411.64
|
| Rate for Payer: Managed Health Services Medicaid |
$9,469.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,067.83
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9,067.83
|
| Rate for Payer: United Healthcare Medicaid |
$9,067.83
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$20,780.89
|
|
|
Service Code
|
APR-DRG 1313
|
| Min. Negotiated Rate |
$18,458.89 |
| Max. Negotiated Rate |
$20,780.89 |
| Rate for Payer: Anthem Medicaid |
$19,898.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$19,898.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19,898.85
|
| Rate for Payer: Dean Health Medicaid |
$19,898.85
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$18,458.89
|
| Rate for Payer: Managed Health Services Medicaid |
$20,780.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,898.85
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19,898.85
|
| Rate for Payer: United Healthcare Medicaid |
$19,898.85
|
|
|
CYSTIC FIBROSIS - PULMONARY DISEASE
|
Facility
|
IP
|
$24,375.90
|
|
|
Service Code
|
APR-DRG 1314
|
| Min. Negotiated Rate |
$21,652.20 |
| Max. Negotiated Rate |
$24,375.90 |
| Rate for Payer: Anthem Medicaid |
$23,341.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$23,341.27
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$23,341.27
|
| Rate for Payer: Dean Health Medicaid |
$23,341.27
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$21,652.20
|
| Rate for Payer: Managed Health Services Medicaid |
$24,375.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$23,341.27
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$23,341.27
|
| Rate for Payer: United Healthcare Medicaid |
$23,341.27
|
|
|
CYSTOGRAFIN diatrizoate 180mg/ml (18%) 300ml soln (MED)
|
Facility
|
IP
|
$236.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
6166129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$120.27 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$147.26
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$181.79
|
|
|
CYSTOGRAFIN diatrizoate 180mg/ml (18%) 300ml soln (MED)
|
Facility
|
OP
|
$236.00
|
|
|
Service Code
|
HCPCS Q9958
|
| Hospital Charge Code |
6166129
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$225.80 |
| Rate for Payer: Aetna Commercial |
$220.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$211.08
|
| Rate for Payer: Aetna Managed Medicare |
$68.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$159.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$122.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$117.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$130.08
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cash Price |
$70.80
|
| Rate for Payer: Cigna Commercial |
$225.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.10
|
| Rate for Payer: Health EOS Commercial |
$218.44
|
| Rate for Payer: HFN Commercial |
$225.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$184.08
|
| Rate for Payer: Multiplan Commercial |
$196.35
|
| Rate for Payer: NAPHCARE Commercial |
$147.26
|
| Rate for Payer: Preferred Network Access Commercial |
$225.80
|
| Rate for Payer: Quartz Beloit One Network |
$120.27
|
| Rate for Payer: Quartz Commercial |
$159.54
|
| Rate for Payer: Quartz Medicare Advantage |
$147.26
|
| Rate for Payer: The Alliance Commercial |
$0.29
|
| Rate for Payer: WEA Trust Commercial |
$134.99
|
| Rate for Payer: WPS Commercial |
$0.19
|
|
|
CYSTOGRAM
|
Facility
|
IP
|
$720.00
|
|
| Hospital Charge Code |
2959978
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$366.91 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$449.28
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
CYSTOGRAM
|
Facility
|
OP
|
$720.00
|
|
| Hospital Charge Code |
2959978
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$209.66 |
| Max. Negotiated Rate |
$688.90 |
| Rate for Payer: Aetna Commercial |
$673.92
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$643.97
|
| Rate for Payer: Aetna Managed Medicare |
$209.66
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$486.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$374.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$359.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$396.86
|
| Rate for Payer: Cash Price |
$216.00
|
| Rate for Payer: Cigna Commercial |
$688.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$419.04
|
| Rate for Payer: Health EOS Commercial |
$666.43
|
| Rate for Payer: HFN Commercial |
$688.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$561.60
|
| Rate for Payer: Multiplan Commercial |
$599.04
|
| Rate for Payer: NAPHCARE Commercial |
$449.28
|
| Rate for Payer: Preferred Network Access Commercial |
$688.90
|
| Rate for Payer: Quartz Beloit One Network |
$366.91
|
| Rate for Payer: Quartz Commercial |
$486.72
|
| Rate for Payer: Quartz Medicare Advantage |
$449.28
|
| Rate for Payer: The Alliance Commercial |
$374.40
|
| Rate for Payer: WEA Trust Commercial |
$411.84
|
| Rate for Payer: WPS Commercial |
$554.62
|
|
|
CYSTOLITHOTOMY
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959980
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
CYSTOLITHOTOMY
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959980
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
CYSTO RECTOCELE REPAIR
|
Facility
|
OP
|
$4,721.00
|
|
| Hospital Charge Code |
2959981
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,374.76 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,374.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,191.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,454.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,356.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,747.62
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,682.38
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: NAPHCARE Commercial |
$2,945.90
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$3,191.40
|
| Rate for Payer: Quartz Medicare Advantage |
$2,945.90
|
| Rate for Payer: The Alliance Commercial |
$2,454.92
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
CYSTO RECTOCELE REPAIR
|
Facility
|
IP
|
$4,721.00
|
|
| Hospital Charge Code |
2959981
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,405.82 |
| Max. Negotiated Rate |
$4,517.05 |
| Rate for Payer: Aetna Commercial |
$4,418.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,222.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,602.22
|
| Rate for Payer: Cash Price |
$1,416.30
|
| Rate for Payer: Cigna Commercial |
$4,517.05
|
| Rate for Payer: Health EOS Commercial |
$4,369.76
|
| Rate for Payer: HFN Commercial |
$4,517.05
|
| Rate for Payer: Multiplan Commercial |
$3,927.87
|
| Rate for Payer: Preferred Network Access Commercial |
$4,517.05
|
| Rate for Payer: Quartz Beloit One Network |
$2,405.82
|
| Rate for Payer: Quartz Commercial |
$2,945.90
|
| Rate for Payer: WEA Trust Commercial |
$2,700.41
|
| Rate for Payer: WPS Commercial |
$3,636.59
|
|
|
CYSTORRHAPHY
|
Facility
|
OP
|
$1,006.00
|
|
| Hospital Charge Code |
2959983
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$292.95 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Aetna Managed Medicare |
$292.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$680.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$523.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$502.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$585.49
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$784.68
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: NAPHCARE Commercial |
$627.74
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$680.06
|
| Rate for Payer: Quartz Medicare Advantage |
$627.74
|
| Rate for Payer: The Alliance Commercial |
$523.12
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
|
CYSTORRHAPHY
|
Facility
|
IP
|
$1,006.00
|
|
| Hospital Charge Code |
2959983
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$512.66 |
| Max. Negotiated Rate |
$962.54 |
| Rate for Payer: Aetna Commercial |
$941.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$899.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$554.51
|
| Rate for Payer: Cash Price |
$301.80
|
| Rate for Payer: Cigna Commercial |
$962.54
|
| Rate for Payer: Health EOS Commercial |
$931.15
|
| Rate for Payer: HFN Commercial |
$962.54
|
| Rate for Payer: Multiplan Commercial |
$836.99
|
| Rate for Payer: Preferred Network Access Commercial |
$962.54
|
| Rate for Payer: Quartz Beloit One Network |
$512.66
|
| Rate for Payer: Quartz Commercial |
$627.74
|
| Rate for Payer: WEA Trust Commercial |
$575.43
|
| Rate for Payer: WPS Commercial |
$774.92
|
|
