|
Influenza B Antibody 86710
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
CPT 86710
|
| Hospital Charge Code |
2942929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.88 |
| Max. Negotiated Rate |
$96.90 |
| Rate for Payer: Aetna Commercial |
$96.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$96.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.20
|
| Rate for Payer: Health EOS Commercial |
$92.82
|
| Rate for Payer: HFN Commercial |
$96.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$47.83
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: Preferred Network Access Commercial |
$96.90
|
| Rate for Payer: Quartz Beloit One Network |
$44.88
|
| Rate for Payer: Quartz Commercial |
$58.14
|
| Rate for Payer: The Alliance Commercial |
$51.00
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Influenza B Antibody 86710
|
Facility
|
IP
|
$102.00
|
|
|
Service Code
|
CPT 86710
|
| Hospital Charge Code |
2942929
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.98 |
| Max. Negotiated Rate |
$93.84 |
| Rate for Payer: Aetna Commercial |
$91.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.06
|
| Rate for Payer: Cash Price |
$30.60
|
| Rate for Payer: Cigna Commercial |
$93.84
|
| Rate for Payer: Health EOS Commercial |
$90.78
|
| Rate for Payer: HFN Commercial |
$93.84
|
| Rate for Payer: Multiplan Commercial |
$81.60
|
| Rate for Payer: NAPHCARE Commercial |
$61.20
|
| Rate for Payer: Preferred Network Access Commercial |
$93.84
|
| Rate for Payer: Quartz Beloit One Network |
$49.98
|
| Rate for Payer: Quartz Commercial |
$61.20
|
| Rate for Payer: WEA Trust Commercial |
$56.10
|
| Rate for Payer: WPS Commercial |
$75.55
|
|
|
Influenza B Antibody 87804
|
Facility
|
IP
|
$233.00
|
|
|
Service Code
|
CPT 87804
|
| Hospital Charge Code |
2942986
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.17 |
| Max. Negotiated Rate |
$214.36 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$139.80
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$139.80
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
Influenza B Antibody 87804
|
Professional
|
Both
|
$233.00
|
|
|
Service Code
|
CPT 87804
|
| Hospital Charge Code |
2942986
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.42 |
| Max. Negotiated Rate |
$221.35 |
| Rate for Payer: Aetna Commercial |
$221.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$221.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$116.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$139.80
|
| Rate for Payer: Health EOS Commercial |
$212.03
|
| Rate for Payer: HFN Commercial |
$221.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$58.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$58.42
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: Preferred Network Access Commercial |
$221.35
|
| Rate for Payer: Quartz Beloit One Network |
$102.52
|
| Rate for Payer: Quartz Commercial |
$132.81
|
| Rate for Payer: The Alliance Commercial |
$116.50
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
Influenza B Antibody 87804
|
Facility
|
OP
|
$233.00
|
|
|
Service Code
|
CPT 87804
|
| Hospital Charge Code |
2942986
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.55 |
| Max. Negotiated Rate |
$214.36 |
| Rate for Payer: Aetna Commercial |
$209.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$200.38
|
| Rate for Payer: Aetna Managed Medicare |
$16.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27.47
|
| Rate for Payer: Anthem Medicaid |
$16.86
|
| Rate for Payer: Anthem Medicare Advantage |
$16.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$123.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.55
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.55
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cash Price |
$69.90
|
| Rate for Payer: Cigna Commercial |
$214.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16.86
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$130.39
|
| Rate for Payer: Dean Health Medicaid |
$16.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.55
|
| Rate for Payer: Health EOS Commercial |
$207.37
|
| Rate for Payer: HFN Commercial |
$214.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.57
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.55
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$16.86
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.55
|
| Rate for Payer: Managed Health Services Medicaid |
$17.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.55
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.55
|
| Rate for Payer: Multiplan Commercial |
$186.40
|
| Rate for Payer: NAPHCARE Commercial |
$24.82
|
| Rate for Payer: Preferred Network Access Commercial |
$214.36
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16.86
|
| Rate for Payer: Quartz Beloit One Network |
$114.17
|
| Rate for Payer: Quartz Commercial |
$151.45
|
| Rate for Payer: Quartz Medicare Advantage |
$16.55
|
| Rate for Payer: The Alliance Commercial |
$66.20
|
| Rate for Payer: United Healthcare Medicaid |
$16.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.55
|
| Rate for Payer: United Healthcare PPO |
$174.75
|
| Rate for Payer: WEA Trust Commercial |
$128.15
|
| Rate for Payer: Wellcare Medicare |
$16.55
|
| Rate for Payer: WMAP Medicaid |
$16.86
|
| Rate for Payer: WPS Commercial |
$172.58
|
|
|
Influenza H1N1 (2009) RNA
|
Facility
|
OP
|
$241.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3881391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Aetna Managed Medicare |
$35.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$131.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.41
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.25
|
| Rate for Payer: Anthem Medicaid |
$36.26
|
| Rate for Payer: Anthem Medicare Advantage |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$35.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$35.09
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$35.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$36.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$134.86
|
| Rate for Payer: Dean Health Medicaid |
$36.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$35.09
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$130.53
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$35.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$36.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$35.09
|
| Rate for Payer: Managed Health Services Medicaid |
$37.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$35.09
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$52.64
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$36.26
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$156.65
|
| Rate for Payer: Quartz Medicare Advantage |
$35.09
|
| Rate for Payer: The Alliance Commercial |
$140.36
|
| Rate for Payer: United Healthcare Medicaid |
$36.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$35.09
|
| Rate for Payer: United Healthcare PPO |
$180.75
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: Wellcare Medicare |
$35.09
|
| Rate for Payer: WMAP Medicaid |
$36.26
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Influenza H1N1 (2009) RNA
|
Professional
|
Both
|
$241.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3881391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$106.04 |
| Max. Negotiated Rate |
$228.95 |
| Rate for Payer: Aetna Commercial |
$228.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$228.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$120.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$144.60
|
| Rate for Payer: Health EOS Commercial |
$219.31
|
| Rate for Payer: HFN Commercial |
$228.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$123.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$123.87
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: Preferred Network Access Commercial |
$228.95
|
| Rate for Payer: Quartz Beloit One Network |
$106.04
|
| Rate for Payer: Quartz Commercial |
$137.37
|
| Rate for Payer: The Alliance Commercial |
$120.50
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Influenza H1N1 (2009) RNA
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
3881391
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.09 |
| Max. Negotiated Rate |
$221.72 |
| Rate for Payer: Aetna Commercial |
$216.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$207.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$127.73
|
| Rate for Payer: Cash Price |
$72.30
|
| Rate for Payer: Cigna Commercial |
$221.72
|
| Rate for Payer: Health EOS Commercial |
$214.49
|
| Rate for Payer: HFN Commercial |
$221.72
|
| Rate for Payer: Multiplan Commercial |
$192.80
|
| Rate for Payer: NAPHCARE Commercial |
$144.60
|
| Rate for Payer: Preferred Network Access Commercial |
$221.72
|
| Rate for Payer: Quartz Beloit One Network |
$118.09
|
| Rate for Payer: Quartz Commercial |
$144.60
|
| Rate for Payer: WEA Trust Commercial |
$132.55
|
| Rate for Payer: WPS Commercial |
$178.51
|
|
|
Infusion Cath 10cm
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549128
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 10cm
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549128
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 10cm
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549128
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,110.56 |
| Max. Negotiated Rate |
$2,397.80 |
| Rate for Payer: Aetna Commercial |
$2,397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,397.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,262.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.40
|
| Rate for Payer: Health EOS Commercial |
$2,296.84
|
| Rate for Payer: HFN Commercial |
$2,397.80
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,110.56
|
| Rate for Payer: Quartz Commercial |
$1,438.68
|
| Rate for Payer: The Alliance Commercial |
$1,262.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 20cm
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549130
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 20cm
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549130
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 20cm
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549130
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,110.56 |
| Max. Negotiated Rate |
$2,397.80 |
| Rate for Payer: Aetna Commercial |
$2,397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,397.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,262.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.40
|
| Rate for Payer: Health EOS Commercial |
$2,296.84
|
| Rate for Payer: HFN Commercial |
$2,397.80
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,110.56
|
| Rate for Payer: Quartz Commercial |
$1,438.68
|
| Rate for Payer: The Alliance Commercial |
$1,262.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 5cm
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,110.56 |
| Max. Negotiated Rate |
$2,397.80 |
| Rate for Payer: Aetna Commercial |
$2,397.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,397.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,262.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,514.40
|
| Rate for Payer: Health EOS Commercial |
$2,296.84
|
| Rate for Payer: HFN Commercial |
$2,397.80
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,397.80
|
| Rate for Payer: Quartz Beloit One Network |
$1,110.56
|
| Rate for Payer: Quartz Commercial |
$1,438.68
|
| Rate for Payer: The Alliance Commercial |
$1,262.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 5cm
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Cath 5cm
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2549126
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
Infusion Catheter-180cm
|
Facility
|
OP
|
$2,748.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
4139305
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$769.44 |
| Max. Negotiated Rate |
$10,992.00 |
| Rate for Payer: Aetna Commercial |
$2,473.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,363.28
|
| Rate for Payer: Aetna Managed Medicare |
$769.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,786.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,374.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,319.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,456.44
|
| Rate for Payer: Cash Price |
$824.40
|
| Rate for Payer: Cigna Commercial |
$2,528.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,537.78
|
| Rate for Payer: Health EOS Commercial |
$2,445.72
|
| Rate for Payer: HFN Commercial |
$2,528.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,061.00
|
| Rate for Payer: Multiplan Commercial |
$2,198.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,648.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,528.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.52
|
| Rate for Payer: Quartz Commercial |
$1,786.20
|
| Rate for Payer: Quartz Medicare Advantage |
$1,648.80
|
| Rate for Payer: The Alliance Commercial |
$10,992.00
|
| Rate for Payer: WEA Trust Commercial |
$1,511.40
|
| Rate for Payer: WPS Commercial |
$2,035.44
|
|
|
Infusion Catheter-180cm
|
Facility
|
IP
|
$2,748.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
4139305
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,346.52 |
| Max. Negotiated Rate |
$2,528.16 |
| Rate for Payer: Aetna Commercial |
$2,473.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,363.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,456.44
|
| Rate for Payer: Cash Price |
$824.40
|
| Rate for Payer: Cigna Commercial |
$2,528.16
|
| Rate for Payer: Health EOS Commercial |
$2,445.72
|
| Rate for Payer: HFN Commercial |
$2,528.16
|
| Rate for Payer: Multiplan Commercial |
$2,198.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,648.80
|
| Rate for Payer: Preferred Network Access Commercial |
$2,528.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,346.52
|
| Rate for Payer: Quartz Commercial |
$1,648.80
|
| Rate for Payer: WEA Trust Commercial |
$1,511.40
|
| Rate for Payer: WPS Commercial |
$2,035.44
|
|
|
INFUSION CATHETER 5FR 10CM
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2972385
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
INFUSION CATHETER 5FR 10CM
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2972385
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
INFUSION CATHETER 5FR 20CM
|
Facility
|
OP
|
$1,991.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
2972386
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$557.48 |
| Max. Negotiated Rate |
$7,964.00 |
| Rate for Payer: Aetna Commercial |
$1,791.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,712.26
|
| Rate for Payer: Aetna Managed Medicare |
$557.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,294.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$995.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$955.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,055.23
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cigna Commercial |
$1,831.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,114.16
|
| Rate for Payer: Health EOS Commercial |
$1,771.99
|
| Rate for Payer: HFN Commercial |
$1,831.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,493.25
|
| Rate for Payer: Multiplan Commercial |
$1,592.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,194.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,831.72
|
| Rate for Payer: Quartz Beloit One Network |
$975.59
|
| Rate for Payer: Quartz Commercial |
$1,294.15
|
| Rate for Payer: Quartz Medicare Advantage |
$1,194.60
|
| Rate for Payer: The Alliance Commercial |
$7,964.00
|
| Rate for Payer: WEA Trust Commercial |
$1,095.05
|
| Rate for Payer: WPS Commercial |
$1,474.73
|
|
|
INFUSION CATHETER 5FR 20CM
|
Facility
|
IP
|
$1,991.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
2972386
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$975.59 |
| Max. Negotiated Rate |
$1,831.72 |
| Rate for Payer: Aetna Commercial |
$1,791.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,712.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,055.23
|
| Rate for Payer: Cash Price |
$597.30
|
| Rate for Payer: Cigna Commercial |
$1,831.72
|
| Rate for Payer: Health EOS Commercial |
$1,771.99
|
| Rate for Payer: HFN Commercial |
$1,831.72
|
| Rate for Payer: Multiplan Commercial |
$1,592.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,194.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,831.72
|
| Rate for Payer: Quartz Beloit One Network |
$975.59
|
| Rate for Payer: Quartz Commercial |
$1,194.60
|
| Rate for Payer: WEA Trust Commercial |
$1,095.05
|
| Rate for Payer: WPS Commercial |
$1,474.73
|
|
|
INFUSION CATHETER 5FR 5CM
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2972384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$706.72 |
| Max. Negotiated Rate |
$10,096.00 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Aetna Managed Medicare |
$706.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,640.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,262.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,211.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,412.43
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,893.00
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,640.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,514.40
|
| Rate for Payer: The Alliance Commercial |
$10,096.00
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
|
INFUSION CATHETER 5FR 5CM
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
2972384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,236.76 |
| Max. Negotiated Rate |
$2,322.08 |
| Rate for Payer: Aetna Commercial |
$2,271.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,170.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,337.72
|
| Rate for Payer: Cash Price |
$757.20
|
| Rate for Payer: Cigna Commercial |
$2,322.08
|
| Rate for Payer: Health EOS Commercial |
$2,246.36
|
| Rate for Payer: HFN Commercial |
$2,322.08
|
| Rate for Payer: Multiplan Commercial |
$2,019.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,514.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,322.08
|
| Rate for Payer: Quartz Beloit One Network |
$1,236.76
|
| Rate for Payer: Quartz Commercial |
$1,514.40
|
| Rate for Payer: WEA Trust Commercial |
$1,388.20
|
| Rate for Payer: WPS Commercial |
$1,869.53
|
|
