|
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
|
|
|
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
|
|
|
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: Cash Price |
$886.50
|
| 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: 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
|
|
|
INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY
|
Facility
|
OP
|
$31.50
|
|
|
Service Code
|
EAPG 00316
|
| Min. Negotiated Rate |
$30.29 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Anthem Medicaid |
$30.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$30.29
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$30.29
|
| Rate for Payer: Dean Health Medicaid |
$30.29
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$30.29
|
| Rate for Payer: Managed Health Services Medicaid |
$31.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.29
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$30.29
|
| Rate for Payer: United Healthcare Medicaid |
$30.29
|
|
|
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 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 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 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
|
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/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 |
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
|
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
|
|
|
Indwelling/Continuous* - Urinary Catheter Type:
|
Facility
|
OP
|
$359.00
|
|
|
Service Code
|
CPT 51702
|
| Hospital Charge Code |
5510857
|
|
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 with Urometer - Urinary Catheter Type
|
Facility
|
OP
|
$477.00
|
|
| Hospital Charge Code |
2999939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$138.90 |
| Max. Negotiated Rate |
$456.39 |
| Rate for Payer: Aetna Commercial |
$446.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.63
|
| Rate for Payer: Aetna Managed Medicare |
$138.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$322.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$248.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$238.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.92
|
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Cigna Commercial |
$456.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$277.61
|
| Rate for Payer: Health EOS Commercial |
$441.51
|
| Rate for Payer: HFN Commercial |
$456.39
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.06
|
| Rate for Payer: Multiplan Commercial |
$396.86
|
| Rate for Payer: NAPHCARE Commercial |
$297.65
|
| Rate for Payer: Preferred Network Access Commercial |
$456.39
|
| Rate for Payer: Quartz Beloit One Network |
$243.08
|
| Rate for Payer: Quartz Commercial |
$322.45
|
| Rate for Payer: Quartz Medicare Advantage |
$297.65
|
| Rate for Payer: The Alliance Commercial |
$248.04
|
| Rate for Payer: WEA Trust Commercial |
$272.84
|
| Rate for Payer: WPS Commercial |
$367.43
|
|
|
Indwelling/Continuous with Urometer - Urinary Catheter Type
|
Facility
|
IP
|
$477.00
|
|
| Hospital Charge Code |
2999939
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$243.08 |
| Max. Negotiated Rate |
$456.39 |
| Rate for Payer: Aetna Commercial |
$446.47
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$426.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$262.92
|
| Rate for Payer: Cash Price |
$143.10
|
| Rate for Payer: Cigna Commercial |
$456.39
|
| Rate for Payer: Health EOS Commercial |
$441.51
|
| Rate for Payer: HFN Commercial |
$456.39
|
| Rate for Payer: Multiplan Commercial |
$396.86
|
| Rate for Payer: Preferred Network Access Commercial |
$456.39
|
| Rate for Payer: Quartz Beloit One Network |
$243.08
|
| Rate for Payer: Quartz Commercial |
$297.65
|
| Rate for Payer: WEA Trust Commercial |
$272.84
|
| Rate for Payer: WPS Commercial |
$367.43
|
|
|
Infant Hearing Screening
|
Facility
|
OP
|
$106.00
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
1188824
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Aetna Managed Medicare |
$30.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$71.66
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$55.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$61.69
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$82.68
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: NAPHCARE Commercial |
$66.14
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$71.66
|
| Rate for Payer: Quartz Medicare Advantage |
$66.14
|
| Rate for Payer: The Alliance Commercial |
$55.12
|
| Rate for Payer: United Healthcare PPO |
$82.68
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
Infant Hearing Screening
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 92650
|
| Hospital Charge Code |
1188824
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$54.02 |
| Max. Negotiated Rate |
$101.42 |
| Rate for Payer: Aetna Commercial |
$99.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$94.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$58.43
|
| Rate for Payer: Cash Price |
$31.80
|
| Rate for Payer: Cigna Commercial |
$101.42
|
| Rate for Payer: Health EOS Commercial |
$98.11
|
| Rate for Payer: HFN Commercial |
$101.42
|
| Rate for Payer: Multiplan Commercial |
$88.19
|
| Rate for Payer: Preferred Network Access Commercial |
$101.42
|
| Rate for Payer: Quartz Beloit One Network |
$54.02
|
| Rate for Payer: Quartz Commercial |
$66.14
|
| Rate for Payer: WEA Trust Commercial |
$60.63
|
| Rate for Payer: WPS Commercial |
$81.65
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC
|
Facility
|
IP
|
$27,778.40
|
|
|
Service Code
|
MSDRG 758
|
| Min. Negotiated Rate |
$8,004.16 |
| Max. Negotiated Rate |
$27,778.40 |
| Rate for Payer: Aetna Managed Medicare |
$8,004.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$21,361.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$16,373.03
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15,555.45
|
| Rate for Payer: Anthem Medicare Advantage |
$8,004.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,004.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,004.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,004.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17,267.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,004.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$20,129.93
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,004.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,004.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,004.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,004.16
|
| Rate for Payer: NAPHCARE Commercial |
$12,006.24
|
| Rate for Payer: Quartz Medicare Advantage |
$8,004.16
|
| Rate for Payer: The Alliance Commercial |
$27,778.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,004.16
|
| Rate for Payer: United Healthcare PPO |
$15,671.41
|
| Rate for Payer: Wellcare Medicare |
$8,004.16
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC
|
Facility
|
IP
|
$41,575.04
|
|
|
Service Code
|
MSDRG 757
|
| Min. Negotiated Rate |
$11,472.54 |
| Max. Negotiated Rate |
$41,575.04 |
| Rate for Payer: Aetna Managed Medicare |
$11,472.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$31,242.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$23,947.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$22,751.63
|
| Rate for Payer: Anthem Medicare Advantage |
$11,472.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$11,472.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$11,472.54
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$11,472.54
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25,256.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$11,472.54
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30,249.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$11,472.54
|
| Rate for Payer: Independent Care Health Plan Medicare |
$11,472.54
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$11,472.54
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$11,472.54
|
| Rate for Payer: NAPHCARE Commercial |
$17,208.81
|
| Rate for Payer: Quartz Medicare Advantage |
$11,472.54
|
| Rate for Payer: The Alliance Commercial |
$41,575.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$11,472.54
|
| Rate for Payer: United Healthcare PPO |
$23,549.74
|
| Rate for Payer: Wellcare Medicare |
$11,472.54
|
|
|
INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC
|
Facility
|
IP
|
$18,200.00
|
|
|
Service Code
|
MSDRG 759
|
| Min. Negotiated Rate |
$5,588.76 |
| Max. Negotiated Rate |
$18,200.00 |
| Rate for Payer: Aetna Managed Medicare |
$5,588.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,479.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,098.21
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,544.02
|
| Rate for Payer: Anthem Medicare Advantage |
$5,588.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,588.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,588.76
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,588.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,704.83
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,588.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,104.94
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,588.76
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,588.76
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,588.76
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,588.76
|
| Rate for Payer: NAPHCARE Commercial |
$8,383.14
|
| Rate for Payer: Quartz Medicare Advantage |
$5,588.76
|
| Rate for Payer: The Alliance Commercial |
$18,200.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,588.76
|
| Rate for Payer: United Healthcare PPO |
$10,202.36
|
| Rate for Payer: Wellcare Medicare |
$5,588.76
|
|
|
INFECTIONS OF UPPER RESPIRATORY TRACT
|
Facility
|
IP
|
$3,419.64
|
|
|
Service Code
|
APR-DRG 1131
|
| Min. Negotiated Rate |
$3,037.54 |
| Max. Negotiated Rate |
$3,419.64 |
| Rate for Payer: Anthem Medicaid |
$3,274.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,274.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,274.49
|
| Rate for Payer: Dean Health Medicaid |
$3,274.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,037.54
|
| Rate for Payer: Managed Health Services Medicaid |
$3,419.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,274.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,274.49
|
| Rate for Payer: United Healthcare Medicaid |
$3,274.49
|
|
