|
INCISOR DEVICE PLUS TRUCLEAR 7209509
|
Facility
|
OP
|
$4,932.00
|
|
| Hospital Charge Code |
5106992
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,436.20 |
| Max. Negotiated Rate |
$4,718.94 |
| Rate for Payer: Aetna Commercial |
$4,616.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,411.18
|
| Rate for Payer: Aetna Managed Medicare |
$1,436.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,334.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,564.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,462.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,718.52
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cigna Commercial |
$4,718.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,870.42
|
| Rate for Payer: Health EOS Commercial |
$4,565.06
|
| Rate for Payer: HFN Commercial |
$4,718.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,846.96
|
| Rate for Payer: Multiplan Commercial |
$4,103.42
|
| Rate for Payer: NAPHCARE Commercial |
$3,077.57
|
| Rate for Payer: Preferred Network Access Commercial |
$4,718.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,513.35
|
| Rate for Payer: Quartz Commercial |
$3,334.03
|
| Rate for Payer: Quartz Medicare Advantage |
$3,077.57
|
| Rate for Payer: The Alliance Commercial |
$2,564.64
|
| Rate for Payer: WEA Trust Commercial |
$2,821.10
|
| Rate for Payer: WPS Commercial |
$3,799.12
|
|
|
INCISOR DEVICE PLUS TRUCLEAR 7209509
|
Facility
|
IP
|
$4,932.00
|
|
| Hospital Charge Code |
5106992
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,513.35 |
| Max. Negotiated Rate |
$4,718.94 |
| Rate for Payer: Aetna Commercial |
$4,616.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,411.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,718.52
|
| Rate for Payer: Cash Price |
$1,479.60
|
| Rate for Payer: Cigna Commercial |
$4,718.94
|
| Rate for Payer: Health EOS Commercial |
$4,565.06
|
| Rate for Payer: HFN Commercial |
$4,718.94
|
| Rate for Payer: Multiplan Commercial |
$4,103.42
|
| Rate for Payer: Preferred Network Access Commercial |
$4,718.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,513.35
|
| Rate for Payer: Quartz Commercial |
$3,077.57
|
| Rate for Payer: WEA Trust Commercial |
$2,821.10
|
| Rate for Payer: WPS Commercial |
$3,799.12
|
|
|
INCISOR DEVICE TRUCLEAR 72202536
|
Facility
|
OP
|
$6,020.00
|
|
| Hospital Charge Code |
5074635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,753.02 |
| Max. Negotiated Rate |
$5,759.94 |
| Rate for Payer: Aetna Commercial |
$5,634.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,384.29
|
| Rate for Payer: Aetna Managed Medicare |
$1,753.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,069.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,130.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,005.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,318.22
|
| Rate for Payer: Cash Price |
$1,806.00
|
| Rate for Payer: Cigna Commercial |
$5,759.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,503.64
|
| Rate for Payer: Health EOS Commercial |
$5,572.11
|
| Rate for Payer: HFN Commercial |
$5,759.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,695.60
|
| Rate for Payer: Multiplan Commercial |
$5,008.64
|
| Rate for Payer: NAPHCARE Commercial |
$3,756.48
|
| Rate for Payer: Preferred Network Access Commercial |
$5,759.94
|
| Rate for Payer: Quartz Beloit One Network |
$3,067.79
|
| Rate for Payer: Quartz Commercial |
$4,069.52
|
| Rate for Payer: Quartz Medicare Advantage |
$3,756.48
|
| Rate for Payer: The Alliance Commercial |
$3,130.40
|
| Rate for Payer: WEA Trust Commercial |
$3,443.44
|
| Rate for Payer: WPS Commercial |
$4,637.21
|
|
|
INCISOR DEVICE TRUCLEAR 72202536
|
Facility
|
IP
|
$6,020.00
|
|
| Hospital Charge Code |
5074635
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,067.79 |
| Max. Negotiated Rate |
$5,759.94 |
| Rate for Payer: Aetna Commercial |
$5,634.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,384.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,318.22
|
| Rate for Payer: Cash Price |
$1,806.00
|
| Rate for Payer: Cigna Commercial |
$5,759.94
|
| Rate for Payer: Health EOS Commercial |
$5,572.11
|
| Rate for Payer: HFN Commercial |
$5,759.94
|
| Rate for Payer: Multiplan Commercial |
$5,008.64
|
| Rate for Payer: Preferred Network Access Commercial |
$5,759.94
|
| Rate for Payer: Quartz Beloit One Network |
$3,067.79
|
| Rate for Payer: Quartz Commercial |
$3,756.48
|
| Rate for Payer: WEA Trust Commercial |
$3,443.44
|
| Rate for Payer: WPS Commercial |
$4,637.21
|
|
|
Inconclusive - Urine Pregnancy POC
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$158.83 |
| Rate for Payer: Aetna Commercial |
$155.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Aetna Managed Medicare |
$8.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.67
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.86
|
| Rate for Payer: Anthem Medicare Advantage |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.95
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$158.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$96.61
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.95
|
| Rate for Payer: Health EOS Commercial |
$153.65
|
| Rate for Payer: HFN Commercial |
$158.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.31
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.95
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: NAPHCARE Commercial |
$13.43
|
| Rate for Payer: Preferred Network Access Commercial |
$158.83
|
| Rate for Payer: Quartz Beloit One Network |
$84.59
|
| Rate for Payer: Quartz Commercial |
$112.22
|
| Rate for Payer: Quartz Medicare Advantage |
$8.95
|
| Rate for Payer: The Alliance Commercial |
$35.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.95
|
| Rate for Payer: United Healthcare PPO |
$129.48
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: Wellcare Medicare |
$8.95
|
| Rate for Payer: WPS Commercial |
$127.87
|
|
|
Inconclusive - Urine Pregnancy POC
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT 81025
|
| Hospital Charge Code |
3120178
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$84.59 |
| Max. Negotiated Rate |
$158.83 |
| Rate for Payer: Aetna Commercial |
$155.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$148.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$91.50
|
| Rate for Payer: Cash Price |
$49.80
|
| Rate for Payer: Cigna Commercial |
$158.83
|
| Rate for Payer: Health EOS Commercial |
$153.65
|
| Rate for Payer: HFN Commercial |
$158.83
|
| Rate for Payer: Multiplan Commercial |
$138.11
|
| Rate for Payer: Preferred Network Access Commercial |
$158.83
|
| Rate for Payer: Quartz Beloit One Network |
$84.59
|
| Rate for Payer: Quartz Commercial |
$103.58
|
| Rate for Payer: WEA Trust Commercial |
$94.95
|
| Rate for Payer: WPS Commercial |
$127.87
|
|
|
Incontinence Service
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005561
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.74 |
| Max. Negotiated Rate |
$459.26 |
| Rate for Payer: Aetna Commercial |
$449.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$429.31
|
| Rate for Payer: Aetna Managed Medicare |
$139.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$324.48
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$249.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$239.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.58
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$459.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$279.36
|
| Rate for Payer: Health EOS Commercial |
$444.29
|
| Rate for Payer: HFN Commercial |
$459.26
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$374.40
|
| Rate for Payer: Multiplan Commercial |
$399.36
|
| Rate for Payer: NAPHCARE Commercial |
$299.52
|
| Rate for Payer: Preferred Network Access Commercial |
$459.26
|
| Rate for Payer: Quartz Beloit One Network |
$244.61
|
| Rate for Payer: Quartz Commercial |
$324.48
|
| Rate for Payer: Quartz Medicare Advantage |
$299.52
|
| Rate for Payer: The Alliance Commercial |
$30.74
|
| Rate for Payer: WEA Trust Commercial |
$274.56
|
| Rate for Payer: WPS Commercial |
$369.74
|
|
|
Incontinence Service
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
3005561
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$244.61 |
| Max. Negotiated Rate |
$459.26 |
| Rate for Payer: Aetna Commercial |
$449.28
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$429.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$264.58
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$459.26
|
| Rate for Payer: Health EOS Commercial |
$444.29
|
| Rate for Payer: HFN Commercial |
$459.26
|
| Rate for Payer: Multiplan Commercial |
$399.36
|
| Rate for Payer: Preferred Network Access Commercial |
$459.26
|
| Rate for Payer: Quartz Beloit One Network |
$244.61
|
| Rate for Payer: Quartz Commercial |
$299.52
|
| Rate for Payer: WEA Trust Commercial |
$274.56
|
| Rate for Payer: WPS Commercial |
$369.74
|
|
|
Indigo Carmine 5ml ampule [Med]
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
2974948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.96 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Aetna Managed Medicare |
$27.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$64.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$55.87
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$74.88
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: NAPHCARE Commercial |
$59.90
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: Quartz Medicare Advantage |
$59.90
|
| Rate for Payer: The Alliance Commercial |
$49.92
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Indigo Carmine 5ml ampule [Med]
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
2974948
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$91.85 |
| Rate for Payer: Aetna Commercial |
$89.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$85.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$52.92
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna Commercial |
$91.85
|
| Rate for Payer: Health EOS Commercial |
$88.86
|
| Rate for Payer: HFN Commercial |
$91.85
|
| Rate for Payer: Multiplan Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$91.85
|
| Rate for Payer: Quartz Beloit One Network |
$48.92
|
| Rate for Payer: Quartz Commercial |
$59.90
|
| Rate for Payer: WEA Trust Commercial |
$54.91
|
| Rate for Payer: WPS Commercial |
$73.95
|
|
|
Indium-111 pentetate (DTPA)
|
Professional
|
Both
|
$2,955.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
2550992
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$226.48 |
| Max. Negotiated Rate |
$2,919.54 |
| Rate for Payer: Aetna Commercial |
$2,919.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,642.95
|
| Rate for Payer: Cash Price |
$886.50
|
| Rate for Payer: Cash Price |
$886.50
|
| Rate for Payer: Cigna Commercial |
$2,919.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$226.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,843.92
|
| Rate for Payer: Health EOS Commercial |
$2,796.61
|
| Rate for Payer: HFN Commercial |
$2,919.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$752.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$752.87
|
| Rate for Payer: Multiplan Commercial |
$2,458.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,919.54
|
| Rate for Payer: Quartz Beloit One Network |
$1,352.21
|
| Rate for Payer: Quartz Commercial |
$1,751.72
|
| Rate for Payer: The Alliance Commercial |
$1,536.60
|
| Rate for Payer: United Healthcare Medicaid |
$226.48
|
| Rate for Payer: WEA Trust Commercial |
$1,690.26
|
| Rate for Payer: WPS Commercial |
$2,276.24
|
|
|
Indium-111 pentetate (DTPA)
|
Facility
|
IP
|
$2,955.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
2550992
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,505.87 |
| Max. Negotiated Rate |
$2,827.34 |
| Rate for Payer: Aetna Commercial |
$2,765.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,642.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,628.80
|
| Rate for Payer: Cash Price |
$886.50
|
| Rate for Payer: Cigna Commercial |
$2,827.34
|
| Rate for Payer: Health EOS Commercial |
$2,735.15
|
| Rate for Payer: HFN Commercial |
$2,827.34
|
| Rate for Payer: Multiplan Commercial |
$2,458.56
|
| Rate for Payer: Preferred Network Access Commercial |
$2,827.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,505.87
|
| Rate for Payer: Quartz Commercial |
$1,843.92
|
| Rate for Payer: WEA Trust Commercial |
$1,690.26
|
| Rate for Payer: WPS Commercial |
$2,276.24
|
|
|
Indium-111 pentetate (DTPA)
|
Facility
|
OP
|
$2,955.00
|
|
|
Service Code
|
HCPCS A9548
|
| Hospital Charge Code |
2550992
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$775.44 |
| Max. Negotiated Rate |
$3,101.78 |
| Rate for Payer: Aetna Commercial |
$2,765.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,642.95
|
| Rate for Payer: Aetna Managed Medicare |
$775.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,997.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,536.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,475.14
|
| Rate for Payer: Anthem Medicare Advantage |
$775.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,628.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$775.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$775.44
|
| Rate for Payer: Cash Price |
$886.50
|
| Rate for Payer: Cash Price |
$886.50
|
| Rate for Payer: Cigna Commercial |
$2,827.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$775.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,719.81
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$775.44
|
| Rate for Payer: Health EOS Commercial |
$2,735.15
|
| Rate for Payer: HFN Commercial |
$2,827.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,884.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$775.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$775.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$775.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$775.44
|
| Rate for Payer: Multiplan Commercial |
$2,458.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,163.17
|
| Rate for Payer: Preferred Network Access Commercial |
$2,827.34
|
| Rate for Payer: Quartz Beloit One Network |
$1,505.87
|
| Rate for Payer: Quartz Commercial |
$1,997.58
|
| Rate for Payer: Quartz Medicare Advantage |
$775.44
|
| Rate for Payer: The Alliance Commercial |
$3,101.78
|
| Rate for Payer: United Healthcare Medicare Advantage |
$775.44
|
| Rate for Payer: WEA Trust Commercial |
$1,690.26
|
| Rate for Payer: Wellcare Medicare |
$775.44
|
| Rate for Payer: WPS Commercial |
$2,276.24
|
|
|
INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY
|
Facility
|
OP
|
$108.75
|
|
|
Service Code
|
EAPG 00316
|
| Min. Negotiated Rate |
$104.57 |
| Max. Negotiated Rate |
$108.75 |
| Rate for Payer: Anthem Medicaid |
$104.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$104.57
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$104.57
|
| Rate for Payer: Dean Health Medicaid |
$104.57
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$104.57
|
| Rate for Payer: Managed Health Services Medicaid |
$108.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$104.57
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$104.57
|
| Rate for Payer: United Healthcare Medicaid |
$104.57
|
|
|
Indwelling catheter latex A4338
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS A4338
|
| Hospital Charge Code |
3133582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.24 |
| Max. Negotiated Rate |
$72.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$5.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.48
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14.04
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$11.23
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| Rate for Payer: Quartz Medicare Advantage |
$11.23
|
| Rate for Payer: The Alliance Commercial |
$72.72
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Indwelling catheter latex A4338
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS A4338
|
| Hospital Charge Code |
3133582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$52.43 |
| Rate for Payer: Aetna Commercial |
$17.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$18.18
|
| Rate for Payer: Anthem Medicare Advantage |
$18.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.18
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.78
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.18
|
| Rate for Payer: Health EOS Commercial |
$17.04
|
| Rate for Payer: HFN Commercial |
$17.78
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.18
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$27.27
|
| Rate for Payer: Preferred Network Access Commercial |
$17.78
|
| Rate for Payer: Quartz Beloit One Network |
$8.24
|
| Rate for Payer: Quartz Commercial |
$10.67
|
| Rate for Payer: Quartz Medicare Advantage |
$18.18
|
| Rate for Payer: The Alliance Commercial |
$49.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.18
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$31.81
|
|
|
Indwelling catheter latex A4338
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS A4338
|
| Hospital Charge Code |
3133582
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Indwelling catheter special A4340
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS A4340
|
| Hospital Charge Code |
3142829
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$135.69 |
| Rate for Payer: Aetna Commercial |
$19.76
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Aetna Managed Medicare |
$47.06
|
| Rate for Payer: Anthem Medicare Advantage |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$47.06
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.06
|
| Rate for Payer: Health EOS Commercial |
$18.93
|
| Rate for Payer: HFN Commercial |
$19.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$135.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$135.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$47.06
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: NAPHCARE Commercial |
$70.59
|
| Rate for Payer: Preferred Network Access Commercial |
$19.76
|
| Rate for Payer: Quartz Beloit One Network |
$9.15
|
| Rate for Payer: Quartz Commercial |
$11.86
|
| Rate for Payer: Quartz Medicare Advantage |
$47.06
|
| Rate for Payer: The Alliance Commercial |
$129.41
|
| Rate for Payer: United Healthcare Medicare Advantage |
$47.06
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$82.36
|
|
|
Indwelling catheter special A4340
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
HCPCS A4340
|
| Hospital Charge Code |
3142829
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.82 |
| Max. Negotiated Rate |
$188.24 |
| Rate for Payer: Aetna Commercial |
$18.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Aetna Managed Medicare |
$5.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$9.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.02
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.64
|
| Rate for Payer: Health EOS Commercial |
$18.51
|
| Rate for Payer: HFN Commercial |
$19.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15.60
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: NAPHCARE Commercial |
$12.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19.14
|
| Rate for Payer: Quartz Beloit One Network |
$10.19
|
| Rate for Payer: Quartz Commercial |
$13.52
|
| Rate for Payer: Quartz Medicare Advantage |
$12.48
|
| Rate for Payer: The Alliance Commercial |
$188.24
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$15.41
|
|
|
Indwelling catheter special A4340
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
HCPCS A4340
|
| Hospital Charge Code |
3142829
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$19.14 |
| Rate for Payer: Aetna Commercial |
$18.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.02
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Cigna Commercial |
$19.14
|
| Rate for Payer: Health EOS Commercial |
$18.51
|
| Rate for Payer: HFN Commercial |
$19.14
|
| Rate for Payer: Multiplan Commercial |
$16.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19.14
|
| Rate for Payer: Quartz Beloit One Network |
$10.19
|
| Rate for Payer: Quartz Commercial |
$12.48
|
| Rate for Payer: WEA Trust Commercial |
$11.44
|
| Rate for Payer: WPS Commercial |
$15.41
|
|
|
Indwelling/Continuous* - Urinary catheter type:
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
5877763
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$182.95 |
| Max. Negotiated Rate |
$343.49 |
| Rate for Payer: Aetna Commercial |
$336.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.88
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$343.49
|
| Rate for Payer: Health EOS Commercial |
$332.29
|
| Rate for Payer: HFN Commercial |
$343.49
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: Preferred Network Access Commercial |
$343.49
|
| Rate for Payer: Quartz Beloit One Network |
$182.95
|
| Rate for Payer: Quartz Commercial |
$224.02
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: WPS Commercial |
$276.54
|
|
|
Indwelling/Continuous* - Urinary catheter type:
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
5877763
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$140.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$336.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$186.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$179.21
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$343.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$332.29
|
| Rate for Payer: HFN Commercial |
$343.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$343.49
|
| Rate for Payer: Quartz Beloit One Network |
$182.95
|
| Rate for Payer: Quartz Commercial |
$242.68
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$280.02
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$276.54
|
|
|
Indwelling/Continuous - Urinary Catheter Type
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
2999940
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$182.95 |
| Max. Negotiated Rate |
$343.49 |
| Rate for Payer: Aetna Commercial |
$336.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.88
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$343.49
|
| Rate for Payer: Health EOS Commercial |
$332.29
|
| Rate for Payer: HFN Commercial |
$343.49
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: Preferred Network Access Commercial |
$343.49
|
| Rate for Payer: Quartz Beloit One Network |
$182.95
|
| Rate for Payer: Quartz Commercial |
$224.02
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: WPS Commercial |
$276.54
|
|
|
Indwelling/Continuous - Urinary Catheter Type
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
2999940
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$140.02 |
| Max. Negotiated Rate |
$4,386.95 |
| Rate for Payer: Aetna Commercial |
$336.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Aetna Managed Medicare |
$140.02
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$242.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$186.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$179.21
|
| Rate for Payer: Anthem Medicare Advantage |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$140.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$140.02
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$343.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$140.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$140.02
|
| Rate for Payer: Health EOS Commercial |
$332.29
|
| Rate for Payer: HFN Commercial |
$343.49
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$520.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$140.02
|
| Rate for Payer: Independent Care Health Plan Medicare |
$140.02
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$140.02
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$140.02
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: NAPHCARE Commercial |
$210.02
|
| Rate for Payer: Preferred Network Access Commercial |
$343.49
|
| Rate for Payer: Quartz Beloit One Network |
$182.95
|
| Rate for Payer: Quartz Commercial |
$242.68
|
| Rate for Payer: Quartz Medicare Advantage |
$140.02
|
| Rate for Payer: The Alliance Commercial |
$560.06
|
| Rate for Payer: United Healthcare Medicare Advantage |
$140.02
|
| Rate for Payer: United Healthcare PPO |
$280.02
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: Wellcare Medicare |
$140.02
|
| Rate for Payer: WPS Commercial |
$276.54
|
|
|
Indwelling/Continuous* - Urinary Catheter Type:
|
Facility
|
IP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
5510857
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$182.95 |
| Max. Negotiated Rate |
$343.49 |
| Rate for Payer: Aetna Commercial |
$336.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$197.88
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$343.49
|
| Rate for Payer: Health EOS Commercial |
$332.29
|
| Rate for Payer: HFN Commercial |
$343.49
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: Preferred Network Access Commercial |
$343.49
|
| Rate for Payer: Quartz Beloit One Network |
$182.95
|
| Rate for Payer: Quartz Commercial |
$224.02
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: WPS Commercial |
$276.54
|
|
