|
Iodine Level
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$24.09 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$24.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$90.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.99
|
| Rate for Payer: Anthem Medicaid |
$24.89
|
| Rate for Payer: Anthem Medicare Advantage |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$24.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$24.09
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$24.09
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$24.89
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Dean Health Medicaid |
$24.89
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$24.09
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$89.61
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$24.09
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$24.89
|
| Rate for Payer: Independent Care Health Plan Medicare |
$24.09
|
| Rate for Payer: Managed Health Services Medicaid |
$25.89
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$24.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$24.09
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$36.14
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$24.89
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$24.09
|
| Rate for Payer: The Alliance Commercial |
$96.36
|
| Rate for Payer: United Healthcare Medicaid |
$24.89
|
| Rate for Payer: United Healthcare Medicare Advantage |
$24.09
|
| Rate for Payer: United Healthcare PPO |
$86.25
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: Wellcare Medicare |
$24.09
|
| Rate for Payer: WMAP Medicaid |
$24.89
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Iodine Level
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$50.60 |
| Max. Negotiated Rate |
$109.25 |
| Rate for Payer: Aetna Commercial |
$109.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$109.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$57.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.00
|
| Rate for Payer: Health EOS Commercial |
$104.65
|
| Rate for Payer: HFN Commercial |
$109.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.04
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$85.04
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: Preferred Network Access Commercial |
$109.25
|
| Rate for Payer: Quartz Beloit One Network |
$50.60
|
| Rate for Payer: Quartz Commercial |
$65.55
|
| Rate for Payer: The Alliance Commercial |
$57.50
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
Iodine Level
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$105.80 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$54.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$81.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$77.40
|
| Rate for Payer: Aetna Managed Medicare |
$25.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$58.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$45.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$43.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$47.70
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$82.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$50.36
|
| Rate for Payer: Health EOS Commercial |
$80.10
|
| Rate for Payer: HFN Commercial |
$82.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$67.50
|
| Rate for Payer: Multiplan Commercial |
$72.00
|
| Rate for Payer: NAPHCARE Commercial |
$54.00
|
| Rate for Payer: Preferred Network Access Commercial |
$82.80
|
| Rate for Payer: Quartz Beloit One Network |
$44.10
|
| Rate for Payer: Quartz Commercial |
$58.50
|
| Rate for Payer: Quartz Medicare Advantage |
$54.00
|
| Rate for Payer: The Alliance Commercial |
$360.00
|
| Rate for Payer: WEA Trust Commercial |
$49.50
|
| Rate for Payer: WPS Commercial |
$66.66
|
|
|
Ion 2.25mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 32mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 32mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 32mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,193.80 |
| Max. Negotiated Rate |
$19,850.25 |
| Rate for Payer: Aetna Commercial |
$19,850.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,850.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,447.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,537.00
|
| Rate for Payer: Health EOS Commercial |
$19,014.45
|
| Rate for Payer: HFN Commercial |
$19,850.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,850.25
|
| Rate for Payer: Quartz Beloit One Network |
$9,193.80
|
| Rate for Payer: Quartz Commercial |
$11,910.15
|
| Rate for Payer: The Alliance Commercial |
$10,447.50
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,850.60 |
| Max. Negotiated Rate |
$83,580.00 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Aetna Managed Medicare |
$5,850.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13,581.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,447.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11,692.84
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$15,671.25
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$13,581.75
|
| Rate for Payer: Quartz Medicare Advantage |
$12,537.00
|
| Rate for Payer: The Alliance Commercial |
$83,580.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
|
Ion 2.25mm x 8mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,238.55 |
| Max. Negotiated Rate |
$19,223.40 |
| Rate for Payer: Aetna Commercial |
$18,805.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17,969.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,074.35
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,223.40
|
| Rate for Payer: Health EOS Commercial |
$18,596.55
|
| Rate for Payer: HFN Commercial |
$19,223.40
|
| Rate for Payer: Multiplan Commercial |
$16,716.00
|
| Rate for Payer: NAPHCARE Commercial |
$12,537.00
|
| Rate for Payer: Preferred Network Access Commercial |
$19,223.40
|
| Rate for Payer: Quartz Beloit One Network |
$10,238.55
|
| Rate for Payer: Quartz Commercial |
$12,537.00
|
| Rate for Payer: WEA Trust Commercial |
$11,492.25
|
| Rate for Payer: WPS Commercial |
$15,476.93
|
|
