|
Ion 5.0mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162956
|
|
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 5.0mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162956
|
|
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 5.0mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162958
|
|
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 5.0mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162958
|
|
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 5.0mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162958
|
|
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 5.0mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162960
|
|
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 5.0mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162960
|
|
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 5.0mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162960
|
|
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 5.0mm x 32mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162962
|
|
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 5.0mm x 32mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162962
|
|
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 5.0mm x 32mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162962
|
|
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
|
|
|
Ipratropium bromide - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5536668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Aetna Managed Medicare |
$10.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.15
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$23.40
|
| Rate for Payer: Quartz Medicare Advantage |
$21.60
|
| Rate for Payer: The Alliance Commercial |
$144.00
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Ipratropium bromide - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5536668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$33.12 |
| Rate for Payer: Aetna Commercial |
$32.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$30.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.08
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$33.12
|
| Rate for Payer: Health EOS Commercial |
$32.04
|
| Rate for Payer: HFN Commercial |
$33.12
|
| Rate for Payer: Multiplan Commercial |
$28.80
|
| Rate for Payer: NAPHCARE Commercial |
$21.60
|
| Rate for Payer: Preferred Network Access Commercial |
$33.12
|
| Rate for Payer: Quartz Beloit One Network |
$17.64
|
| Rate for Payer: Quartz Commercial |
$21.60
|
| Rate for Payer: WEA Trust Commercial |
$19.80
|
| Rate for Payer: WPS Commercial |
$26.67
|
|
|
Iridotomy/Iridectomy by Laser Surgery
|
Professional
|
Both
|
$1,541.00
|
|
|
Service Code
|
CPT 66761
|
| Hospital Charge Code |
1188903
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$353.32 |
| Max. Negotiated Rate |
$1,463.95 |
| Rate for Payer: Aetna Commercial |
$1,463.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,325.26
|
| Rate for Payer: Cash Price |
$462.30
|
| Rate for Payer: Cash Price |
$462.30
|
| Rate for Payer: Cash Price |
$462.30
|
| Rate for Payer: Cigna Commercial |
$1,463.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$353.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$924.60
|
| Rate for Payer: Health EOS Commercial |
$1,402.31
|
| Rate for Payer: HFN Commercial |
$1,463.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$795.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$795.24
|
| Rate for Payer: Multiplan Commercial |
$1,232.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,463.95
|
| Rate for Payer: Quartz Beloit One Network |
$678.04
|
| Rate for Payer: Quartz Commercial |
$878.37
|
| Rate for Payer: The Alliance Commercial |
$770.50
|
| Rate for Payer: United Healthcare Medicaid |
$353.32
|
| Rate for Payer: WEA Trust Commercial |
$847.55
|
| Rate for Payer: WPS Commercial |
$1,141.42
|
|
|
Iron Binding Capacity Total
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$89.18 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$109.20
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$109.20
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Iron Binding Capacity Total
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$167.44 |
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Aetna Managed Medicare |
$8.74
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$32.78
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$14.51
|
| Rate for Payer: Anthem Medicaid |
$9.03
|
| Rate for Payer: Anthem Medicare Advantage |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$96.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8.74
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$167.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8.74
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$101.85
|
| Rate for Payer: Dean Health Medicaid |
$9.03
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8.74
|
| Rate for Payer: Health EOS Commercial |
$161.98
|
| Rate for Payer: HFN Commercial |
$167.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.51
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8.74
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$9.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8.74
|
| Rate for Payer: Managed Health Services Medicaid |
$9.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8.74
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8.74
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: NAPHCARE Commercial |
$13.11
|
| Rate for Payer: Preferred Network Access Commercial |
$167.44
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$9.03
|
| Rate for Payer: Quartz Beloit One Network |
$89.18
|
| Rate for Payer: Quartz Commercial |
$118.30
|
| Rate for Payer: Quartz Medicare Advantage |
$8.74
|
| Rate for Payer: The Alliance Commercial |
$34.96
|
| Rate for Payer: United Healthcare Medicaid |
$9.03
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8.74
|
| Rate for Payer: United Healthcare PPO |
$136.50
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: Wellcare Medicare |
$8.74
|
| Rate for Payer: WMAP Medicaid |
$9.03
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Iron Binding Capacity Total
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.85 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna Commercial |
$172.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$156.52
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$172.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$91.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$109.20
|
| Rate for Payer: Health EOS Commercial |
$165.62
|
| Rate for Payer: HFN Commercial |
$172.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$30.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$30.85
|
| Rate for Payer: Multiplan Commercial |
$145.60
|
| Rate for Payer: Preferred Network Access Commercial |
$172.90
|
| Rate for Payer: Quartz Beloit One Network |
$80.08
|
| Rate for Payer: Quartz Commercial |
$103.74
|
| Rate for Payer: The Alliance Commercial |
$91.00
|
| Rate for Payer: WEA Trust Commercial |
$100.10
|
| Rate for Payer: WPS Commercial |
$134.81
|
|
|
Iron Level
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$82.80
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$82.80
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Iron Level
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.84 |
| Max. Negotiated Rate |
$131.10 |
| Rate for Payer: Aetna Commercial |
$131.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$131.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$69.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$82.80
|
| Rate for Payer: Health EOS Commercial |
$125.58
|
| Rate for Payer: HFN Commercial |
$131.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$22.84
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$22.84
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: Preferred Network Access Commercial |
$131.10
|
| Rate for Payer: Quartz Beloit One Network |
$60.72
|
| Rate for Payer: Quartz Commercial |
$78.66
|
| Rate for Payer: The Alliance Commercial |
$69.00
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Iron Level
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.47 |
| Max. Negotiated Rate |
$126.96 |
| Rate for Payer: Aetna Commercial |
$124.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$118.68
|
| Rate for Payer: Aetna Managed Medicare |
$6.47
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.26
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.74
|
| Rate for Payer: Anthem Medicaid |
$6.69
|
| Rate for Payer: Anthem Medicare Advantage |
$6.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$73.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.47
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$126.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.47
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$77.22
|
| Rate for Payer: Dean Health Medicaid |
$6.69
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.47
|
| Rate for Payer: Health EOS Commercial |
$122.82
|
| Rate for Payer: HFN Commercial |
$126.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$24.07
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.47
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.47
|
| Rate for Payer: Managed Health Services Medicaid |
$6.96
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.47
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.47
|
| Rate for Payer: Multiplan Commercial |
$110.40
|
| Rate for Payer: NAPHCARE Commercial |
$9.70
|
| Rate for Payer: Preferred Network Access Commercial |
$126.96
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$6.69
|
| Rate for Payer: Quartz Beloit One Network |
$67.62
|
| Rate for Payer: Quartz Commercial |
$89.70
|
| Rate for Payer: Quartz Medicare Advantage |
$6.47
|
| Rate for Payer: The Alliance Commercial |
$25.88
|
| Rate for Payer: United Healthcare Medicaid |
$6.69
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.47
|
| Rate for Payer: United Healthcare PPO |
$103.50
|
| Rate for Payer: WEA Trust Commercial |
$75.90
|
| Rate for Payer: Wellcare Medicare |
$6.47
|
| Rate for Payer: WMAP Medicaid |
$6.69
|
| Rate for Payer: WPS Commercial |
$102.22
|
|
|
Iron sucrose injection 1 Mg J1756
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
3382913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.49 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.60
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.74
|
|
|
Iron sucrose injection 1 Mg J1756
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
3382913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.95 |
| Rate for Payer: Aetna Commercial |
$0.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.23
|
| Rate for Payer: Health EOS Commercial |
$0.91
|
| Rate for Payer: HFN Commercial |
$0.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.34
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: Preferred Network Access Commercial |
$0.95
|
| Rate for Payer: Quartz Beloit One Network |
$0.44
|
| Rate for Payer: Quartz Commercial |
$0.57
|
| Rate for Payer: The Alliance Commercial |
$0.50
|
| Rate for Payer: United Healthcare Medicaid |
$0.22
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.57
|
|
|
Iron sucrose injection 1 Mg J1756
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
HCPCS J1756
|
| Hospital Charge Code |
3382913
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.86
|
| Rate for Payer: Aetna Managed Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.53
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.30
|
| Rate for Payer: Health EOS Commercial |
$0.89
|
| Rate for Payer: HFN Commercial |
$0.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$0.80
|
| Rate for Payer: NAPHCARE Commercial |
$0.60
|
| Rate for Payer: Preferred Network Access Commercial |
$0.92
|
| Rate for Payer: Quartz Beloit One Network |
$0.49
|
| Rate for Payer: Quartz Commercial |
$0.65
|
| Rate for Payer: Quartz Medicare Advantage |
$0.60
|
| Rate for Payer: The Alliance Commercial |
$4.00
|
| Rate for Payer: WEA Trust Commercial |
$0.55
|
| Rate for Payer: WPS Commercial |
$0.57
|
|
|
Irradiation Fee
|
Professional
|
Both
|
$181.00
|
|
|
Service Code
|
CPT 86945
|
| Hospital Charge Code |
2949312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.64 |
| Max. Negotiated Rate |
$171.95 |
| Rate for Payer: Aetna Commercial |
$171.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$171.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$90.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.60
|
| Rate for Payer: Health EOS Commercial |
$164.71
|
| Rate for Payer: HFN Commercial |
$171.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$100.96
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$100.96
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: Preferred Network Access Commercial |
$171.95
|
| Rate for Payer: Quartz Beloit One Network |
$79.64
|
| Rate for Payer: Quartz Commercial |
$103.17
|
| Rate for Payer: The Alliance Commercial |
$90.50
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
|
Irradiation Fee
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 86945
|
| Hospital Charge Code |
2949312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$166.52 |
| Rate for Payer: Aetna Commercial |
$162.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$155.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$95.93
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$166.52
|
| Rate for Payer: Health EOS Commercial |
$161.09
|
| Rate for Payer: HFN Commercial |
$166.52
|
| Rate for Payer: Multiplan Commercial |
$144.80
|
| Rate for Payer: NAPHCARE Commercial |
$108.60
|
| Rate for Payer: Preferred Network Access Commercial |
$166.52
|
| Rate for Payer: Quartz Beloit One Network |
$88.69
|
| Rate for Payer: Quartz Commercial |
$108.60
|
| Rate for Payer: WEA Trust Commercial |
$99.55
|
| Rate for Payer: WPS Commercial |
$134.07
|
|
