|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT;
|
Facility
|
OP
|
$6,626.51
|
|
|
Service Code
|
CPT 36901
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,656.63 |
| Max. Negotiated Rate |
$6,626.51 |
| Rate for Payer: Aetna Managed Medicare |
$1,656.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,635.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,985.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,835.04
|
| Rate for Payer: Anthem Medicare Advantage |
$1,656.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,656.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,656.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,656.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,656.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,162.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,656.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,656.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,656.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,656.63
|
| Rate for Payer: NAPHCARE Commercial |
$2,484.94
|
| Rate for Payer: Quartz Medicare Advantage |
$1,656.63
|
| Rate for Payer: The Alliance Commercial |
$6,626.51
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,656.63
|
| Rate for Payer: United Healthcare PPO |
$3,726.32
|
| Rate for Payer: Wellcare Medicare |
$1,656.63
|
|
|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE STENTING, AND ALL ANGIOPLASTY WITHIN THE PERIPHERAL DIALYSIS SEGMENT
|
Facility
|
OP
|
$45,194.20
|
|
|
Service Code
|
CPT 36903
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,386.95 |
| Max. Negotiated Rate |
$45,194.20 |
| Rate for Payer: Aetna Managed Medicare |
$12,148.98
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$19,394.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19,394.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,919.20
|
| Rate for Payer: Anthem Medicare Advantage |
$12,148.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,148.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,148.98
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,148.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,148.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45,194.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,148.98
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,148.98
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,148.98
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,148.98
|
| Rate for Payer: NAPHCARE Commercial |
$18,223.47
|
| Rate for Payer: Quartz Medicare Advantage |
$12,148.98
|
| Rate for Payer: The Alliance Commercial |
$20,653.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,148.98
|
| Rate for Payer: United Healthcare PPO |
$9,979.84
|
| Rate for Payer: Wellcare Medicare |
$12,148.98
|
|
|
INTRODUCTION OF NEEDLE(S) AND/OR CATHETER(S), DIALYSIS CIRCUIT, WITH DIAGNOSTIC ANGIOGRAPHY OF THE DIALYSIS CIRCUIT, INCLUDING ALL DIRECT PUNCTURE(S) AND CATHETER PLACEMENT(S), INJECTION(S) OF CONTRAST, ALL NECESSARY IMAGING FROM THE ARTERIAL ANASTOMOSIS AND ADJACENT ARTERY THROUGH ENTIRE VENOUS OUTFLOW INCLUDING THE INFERIOR OR SUPERIOR VENA CAVA, FLUOROSCOPIC GUIDANCE, RADIOLOGICAL SUPERVISION AND INTERPRETATION AND IMAGE DOCUMENTATION AND REPORT; WITH TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL DIALYSIS SEGMENT, INCLUDING ALL IMAGING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION NECESSARY TO PERFORM THE ANGIOPLASTY
|
Facility
|
OP
|
$22,281.85
|
|
|
Service Code
|
CPT 36902
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,386.95 |
| Max. Negotiated Rate |
$22,281.85 |
| Rate for Payer: Aetna Managed Medicare |
$5,989.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,970.72
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,336.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,619.84
|
| Rate for Payer: Anthem Medicare Advantage |
$5,989.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,989.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,989.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,989.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,386.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,989.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22,281.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,989.74
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,989.74
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,989.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,989.74
|
| Rate for Payer: NAPHCARE Commercial |
$8,984.62
|
| Rate for Payer: Quartz Medicare Advantage |
$5,989.74
|
| Rate for Payer: The Alliance Commercial |
$10,182.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,989.74
|
| Rate for Payer: United Healthcare PPO |
$6,400.16
|
| Rate for Payer: Wellcare Medicare |
$5,989.74
|
|
|
Intro Transhepatic Catheter
|
Facility
|
IP
|
$3,457.00
|
|
|
Service Code
|
CPT 47510
|
| Hospital Charge Code |
3072749
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,761.69 |
| Max. Negotiated Rate |
$3,307.66 |
| Rate for Payer: Aetna Commercial |
$3,235.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,091.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,905.50
|
| Rate for Payer: Cash Price |
$1,037.10
|
| Rate for Payer: Cigna Commercial |
$3,307.66
|
| Rate for Payer: Health EOS Commercial |
$3,199.80
|
| Rate for Payer: HFN Commercial |
$3,307.66
|
| Rate for Payer: Multiplan Commercial |
$2,876.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,307.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,761.69
|
| Rate for Payer: Quartz Commercial |
$2,157.17
|
| Rate for Payer: WEA Trust Commercial |
$1,977.40
|
| Rate for Payer: WPS Commercial |
$2,662.93
|
|
|
Intro Transhepatic Catheter
|
Professional
|
Both
|
$3,457.00
|
|
|
Service Code
|
CPT 47510
|
| Hospital Charge Code |
3072749
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,581.92 |
| Max. Negotiated Rate |
$3,415.52 |
| Rate for Payer: Aetna Commercial |
$3,415.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,091.94
|
| Rate for Payer: Cash Price |
$1,037.10
|
| Rate for Payer: Cash Price |
$1,037.10
|
| Rate for Payer: Cigna Commercial |
$3,415.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,797.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,157.17
|
| Rate for Payer: Health EOS Commercial |
$3,271.70
|
| Rate for Payer: HFN Commercial |
$3,415.52
|
| Rate for Payer: Multiplan Commercial |
$2,876.22
|
| Rate for Payer: Preferred Network Access Commercial |
$3,415.52
|
| Rate for Payer: Quartz Beloit One Network |
$1,581.92
|
| Rate for Payer: Quartz Commercial |
$2,049.31
|
| Rate for Payer: The Alliance Commercial |
$1,797.64
|
| Rate for Payer: WEA Trust Commercial |
$1,977.40
|
| Rate for Payer: WPS Commercial |
$2,662.93
|
|
|
Intro Transhepatic Catheter
|
Facility
|
OP
|
$3,457.00
|
|
|
Service Code
|
CPT 47510
|
| Hospital Charge Code |
3072749
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,006.68 |
| Max. Negotiated Rate |
$3,307.66 |
| Rate for Payer: Aetna Commercial |
$3,235.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,091.94
|
| Rate for Payer: Aetna Managed Medicare |
$1,006.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,336.93
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,797.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,725.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,905.50
|
| Rate for Payer: Cash Price |
$1,037.10
|
| Rate for Payer: Cash Price |
$1,037.10
|
| Rate for Payer: Cigna Commercial |
$3,307.66
|
| Rate for Payer: Health EOS Commercial |
$3,199.80
|
| Rate for Payer: HFN Commercial |
$3,307.66
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,696.46
|
| Rate for Payer: Multiplan Commercial |
$2,876.22
|
| Rate for Payer: NAPHCARE Commercial |
$2,157.17
|
| Rate for Payer: Preferred Network Access Commercial |
$3,307.66
|
| Rate for Payer: Quartz Beloit One Network |
$1,761.69
|
| Rate for Payer: Quartz Commercial |
$2,336.93
|
| Rate for Payer: Quartz Medicare Advantage |
$2,157.17
|
| Rate for Payer: The Alliance Commercial |
$1,797.64
|
| Rate for Payer: WEA Trust Commercial |
$1,977.40
|
| Rate for Payer: WPS Commercial |
$2,662.93
|
|
|
INTUBATOR PINK AIRWAY 10cm #1-1503-10
|
Facility
|
IP
|
$104.00
|
|
| Hospital Charge Code |
2974540
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.00 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$64.90
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
INTUBATOR PINK AIRWAY 10cm #1-1503-10
|
Facility
|
OP
|
$104.00
|
|
| Hospital Charge Code |
2974540
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.28 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Commercial |
$97.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$93.02
|
| Rate for Payer: Aetna Managed Medicare |
$30.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$54.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$51.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$57.32
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$99.51
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$60.53
|
| Rate for Payer: Health EOS Commercial |
$96.26
|
| Rate for Payer: HFN Commercial |
$99.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$81.12
|
| Rate for Payer: Multiplan Commercial |
$86.53
|
| Rate for Payer: NAPHCARE Commercial |
$64.90
|
| Rate for Payer: Preferred Network Access Commercial |
$99.51
|
| Rate for Payer: Quartz Beloit One Network |
$53.00
|
| Rate for Payer: Quartz Commercial |
$70.30
|
| Rate for Payer: Quartz Medicare Advantage |
$64.90
|
| Rate for Payer: The Alliance Commercial |
$54.08
|
| Rate for Payer: WEA Trust Commercial |
$59.49
|
| Rate for Payer: WPS Commercial |
$80.11
|
|
|
INTUBATOR PINK AIRWAY 9cm #1-1503-09
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
2974538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
INTUBATOR PINK AIRWAY 9cm #1-1503-09
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
2974538
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
INTUSSUSCEPTION
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2960159
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
INTUSSUSCEPTION
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2960159
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
Iodine 24 Hour Urine
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
1040832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.78 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
Iodine 24 Hour Urine
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
1040832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Aetna Managed Medicare |
$25.07
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$94.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.62
|
| Rate for Payer: Anthem Medicare Advantage |
$25.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.07
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$168.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.07
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.28
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.07
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.07
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.07
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.07
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: NAPHCARE Commercial |
$37.61
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$196.04
|
| Rate for Payer: Quartz Medicare Advantage |
$25.07
|
| Rate for Payer: The Alliance Commercial |
$100.30
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.07
|
| Rate for Payer: United Healthcare PPO |
$226.20
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: Wellcare Medicare |
$25.07
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
Iodine 24 Hour Urine
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
1040832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$286.52 |
| Rate for Payer: Aetna Commercial |
$286.52
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Aetna Managed Medicare |
$25.07
|
| Rate for Payer: Anthem Medicare Advantage |
$25.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.07
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$286.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$150.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.07
|
| Rate for Payer: Health EOS Commercial |
$274.46
|
| Rate for Payer: HFN Commercial |
$286.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.51
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.07
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: NAPHCARE Commercial |
$37.61
|
| Rate for Payer: Preferred Network Access Commercial |
$286.52
|
| Rate for Payer: Quartz Beloit One Network |
$132.70
|
| Rate for Payer: Quartz Commercial |
$171.91
|
| Rate for Payer: Quartz Medicare Advantage |
$25.07
|
| Rate for Payer: The Alliance Commercial |
$99.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.07
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$110.33
|
|
|
Iodine Level
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$113.62 |
| Rate for Payer: Aetna Commercial |
$113.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$113.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$108.84
|
| Rate for Payer: HFN Commercial |
$113.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$113.62
|
| Rate for Payer: Quartz Beloit One Network |
$52.62
|
| Rate for Payer: Quartz Commercial |
$68.17
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
Iodine Level
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
Iodine Level
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$89.70
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
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 |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
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 |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
