|
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 |
$9,561.55 |
| 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
|
|
|
Ipratropium bromide - Additional Unit Dose Medicaiton
|
Facility
|
OP
|
$36.00
|
|
| Hospital Charge Code |
5536668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.48 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Aetna Managed Medicare |
$10.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.34
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.95
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.08
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: NAPHCARE Commercial |
$22.46
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$24.34
|
| Rate for Payer: Quartz Medicare Advantage |
$22.46
|
| Rate for Payer: The Alliance Commercial |
$18.72
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
Ipratropium bromide - Additional Unit Dose Medicaiton
|
Facility
|
IP
|
$36.00
|
|
| Hospital Charge Code |
5536668
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$34.44 |
| Rate for Payer: Aetna Commercial |
$33.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$19.84
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna Commercial |
$34.44
|
| Rate for Payer: Health EOS Commercial |
$33.32
|
| Rate for Payer: HFN Commercial |
$34.44
|
| Rate for Payer: Multiplan Commercial |
$29.95
|
| Rate for Payer: Preferred Network Access Commercial |
$34.44
|
| Rate for Payer: Quartz Beloit One Network |
$18.35
|
| Rate for Payer: Quartz Commercial |
$22.46
|
| Rate for Payer: WEA Trust Commercial |
$20.59
|
| Rate for Payer: WPS Commercial |
$27.73
|
|
|
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 |
$200.64 |
| Max. Negotiated Rate |
$1,522.51 |
| Rate for Payer: Aetna Commercial |
$1,522.51
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,378.27
|
| Rate for Payer: Aetna Managed Medicare |
$200.64
|
| Rate for Payer: Anthem Medicare Advantage |
$200.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$200.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$200.64
|
| 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 |
$1,522.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$367.45
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.64
|
| Rate for Payer: Health EOS Commercial |
$1,458.40
|
| Rate for Payer: HFN Commercial |
$1,522.51
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$827.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$827.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$200.64
|
| Rate for Payer: Multiplan Commercial |
$1,282.11
|
| Rate for Payer: NAPHCARE Commercial |
$300.96
|
| Rate for Payer: Preferred Network Access Commercial |
$1,522.51
|
| Rate for Payer: Quartz Beloit One Network |
$705.16
|
| Rate for Payer: Quartz Commercial |
$913.50
|
| Rate for Payer: Quartz Medicare Advantage |
$200.64
|
| Rate for Payer: The Alliance Commercial |
$852.71
|
| Rate for Payer: United Healthcare Medicaid |
$367.45
|
| Rate for Payer: United Healthcare Medicare Advantage |
$200.64
|
| Rate for Payer: WEA Trust Commercial |
$881.45
|
| Rate for Payer: WPS Commercial |
$902.87
|
|
|
Iron Binding Capacity Total
|
Professional
|
Both
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$179.82 |
| Rate for Payer: Aetna Commercial |
$179.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$9.09
|
| Rate for Payer: Anthem Medicare Advantage |
$9.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.09
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$179.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9.09
|
| Rate for Payer: Health EOS Commercial |
$172.24
|
| Rate for Payer: HFN Commercial |
$179.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$32.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.09
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$13.63
|
| Rate for Payer: Preferred Network Access Commercial |
$179.82
|
| Rate for Payer: Quartz Beloit One Network |
$83.28
|
| Rate for Payer: Quartz Commercial |
$107.89
|
| Rate for Payer: Quartz Medicare Advantage |
$9.09
|
| Rate for Payer: The Alliance Commercial |
$35.90
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.09
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$39.99
|
|
|
Iron Binding Capacity Total
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.09 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Aetna Managed Medicare |
$9.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.09
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$15.91
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$15.09
|
| Rate for Payer: Anthem Medicare Advantage |
$9.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$9.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$9.09
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$9.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.92
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$9.09
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$33.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$9.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$9.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$9.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$9.09
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: NAPHCARE Commercial |
$13.63
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$123.03
|
| Rate for Payer: Quartz Medicare Advantage |
$9.09
|
| Rate for Payer: The Alliance Commercial |
$36.36
|
| Rate for Payer: United Healthcare Medicare Advantage |
$9.09
|
| Rate for Payer: United Healthcare PPO |
$141.96
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: Wellcare Medicare |
$9.09
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
Iron Binding Capacity Total
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
CPT 83550
|
| Hospital Charge Code |
633764
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$174.14 |
| Rate for Payer: Aetna Commercial |
$170.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$162.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$100.32
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cigna Commercial |
$174.14
|
| Rate for Payer: Health EOS Commercial |
$168.46
|
| Rate for Payer: HFN Commercial |
$174.14
|
| Rate for Payer: Multiplan Commercial |
$151.42
|
| Rate for Payer: Preferred Network Access Commercial |
$174.14
|
| Rate for Payer: Quartz Beloit One Network |
$92.75
|
| Rate for Payer: Quartz Commercial |
$113.57
|
| Rate for Payer: WEA Trust Commercial |
$104.10
|
| Rate for Payer: WPS Commercial |
$140.19
|
|
|
Iron Level
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$6.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$25.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11.17
|
| Rate for Payer: Anthem Medicare Advantage |
$6.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.73
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6.73
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.32
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6.73
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$25.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6.73
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.73
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6.73
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6.73
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$10.09
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$93.29
|
| Rate for Payer: Quartz Medicare Advantage |
$6.73
|
| Rate for Payer: The Alliance Commercial |
$26.92
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.73
|
| Rate for Payer: United Healthcare PPO |
$107.64
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: Wellcare Medicare |
$6.73
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
Iron Level
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.73 |
| Max. Negotiated Rate |
$136.34 |
| Rate for Payer: Aetna Commercial |
$136.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Aetna Managed Medicare |
$6.73
|
| Rate for Payer: Anthem Medicare Advantage |
$6.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6.73
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$136.34
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.73
|
| Rate for Payer: Health EOS Commercial |
$130.60
|
| Rate for Payer: HFN Commercial |
$136.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$23.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$23.75
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6.73
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: NAPHCARE Commercial |
$10.09
|
| Rate for Payer: Preferred Network Access Commercial |
$136.34
|
| Rate for Payer: Quartz Beloit One Network |
$63.15
|
| Rate for Payer: Quartz Commercial |
$81.81
|
| Rate for Payer: Quartz Medicare Advantage |
$6.73
|
| Rate for Payer: The Alliance Commercial |
$26.58
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6.73
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$29.61
|
|
|
Iron Level
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
633765
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.32 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$129.17
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$123.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.07
|
| Rate for Payer: Cash Price |
$41.40
|
| Rate for Payer: Cigna Commercial |
$132.04
|
| Rate for Payer: Health EOS Commercial |
$127.73
|
| Rate for Payer: HFN Commercial |
$132.04
|
| Rate for Payer: Multiplan Commercial |
$114.82
|
| Rate for Payer: Preferred Network Access Commercial |
$132.04
|
| Rate for Payer: Quartz Beloit One Network |
$70.32
|
| Rate for Payer: Quartz Commercial |
$86.11
|
| Rate for Payer: WEA Trust Commercial |
$78.94
|
| Rate for Payer: WPS Commercial |
$106.30
|
|
|
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 |
$0.29 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.89
|
| Rate for Payer: Aetna Managed Medicare |
$0.29
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$0.68
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$0.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.32
|
| Rate for Payer: Health EOS Commercial |
$0.93
|
| Rate for Payer: HFN Commercial |
$0.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.78
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: NAPHCARE Commercial |
$0.62
|
| Rate for Payer: Preferred Network Access Commercial |
$0.96
|
| Rate for Payer: Quartz Beloit One Network |
$0.51
|
| Rate for Payer: Quartz Commercial |
$0.68
|
| Rate for Payer: Quartz Medicare Advantage |
$0.62
|
| Rate for Payer: The Alliance Commercial |
$1.00
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.60
|
|
|
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 |
$0.24 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.89
|
| Rate for Payer: Aetna Managed Medicare |
$0.25
|
| Rate for Payer: Anthem Medicare Advantage |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.25
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.24
|
| Rate for Payer: Health EOS Commercial |
$0.95
|
| Rate for Payer: HFN Commercial |
$0.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: NAPHCARE Commercial |
$0.37
|
| Rate for Payer: Preferred Network Access Commercial |
$0.99
|
| Rate for Payer: Quartz Beloit One Network |
$0.46
|
| Rate for Payer: Quartz Commercial |
$0.59
|
| Rate for Payer: Quartz Medicare Advantage |
$0.25
|
| Rate for Payer: The Alliance Commercial |
$0.69
|
| Rate for Payer: United Healthcare Medicaid |
$0.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.25
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.60
|
|
|
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 |
$0.51 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna Commercial |
$0.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$0.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$0.55
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna Commercial |
$0.96
|
| Rate for Payer: Health EOS Commercial |
$0.93
|
| Rate for Payer: HFN Commercial |
$0.96
|
| Rate for Payer: Multiplan Commercial |
$0.83
|
| Rate for Payer: Preferred Network Access Commercial |
$0.96
|
| Rate for Payer: Quartz Beloit One Network |
$0.51
|
| Rate for Payer: Quartz Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.77
|
|
|
Irradiation Fee
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
CPT 86945
|
| Hospital Charge Code |
2949312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Aetna Managed Medicare |
$39.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$154.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.14
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$68.43
|
| Rate for Payer: Anthem Medicare Advantage |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$39.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$39.31
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$39.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.34
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$39.31
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$146.24
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$39.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$39.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$39.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$39.31
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: NAPHCARE Commercial |
$58.97
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$122.36
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$157.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$39.31
|
| Rate for Payer: United Healthcare PPO |
$141.18
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: Wellcare Medicare |
$39.31
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
Irradiation Fee
|
Professional
|
Both
|
$181.00
|
|
|
Service Code
|
CPT 86945
|
| Hospital Charge Code |
2949312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.83 |
| Max. Negotiated Rate |
$178.83 |
| Rate for Payer: Aetna Commercial |
$178.83
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$178.83
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$94.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$112.94
|
| Rate for Payer: Health EOS Commercial |
$171.30
|
| Rate for Payer: HFN Commercial |
$178.83
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.00
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: Preferred Network Access Commercial |
$178.83
|
| Rate for Payer: Quartz Beloit One Network |
$82.83
|
| Rate for Payer: Quartz Commercial |
$107.30
|
| Rate for Payer: The Alliance Commercial |
$94.12
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
Irradiation Fee
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 86945
|
| Hospital Charge Code |
2949312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$92.24 |
| Max. Negotiated Rate |
$173.18 |
| Rate for Payer: Aetna Commercial |
$169.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.89
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.77
|
| Rate for Payer: Cash Price |
$54.30
|
| Rate for Payer: Cigna Commercial |
$173.18
|
| Rate for Payer: Health EOS Commercial |
$167.53
|
| Rate for Payer: HFN Commercial |
$173.18
|
| Rate for Payer: Multiplan Commercial |
$150.59
|
| Rate for Payer: Preferred Network Access Commercial |
$173.18
|
| Rate for Payer: Quartz Beloit One Network |
$92.24
|
| Rate for Payer: Quartz Commercial |
$112.94
|
| Rate for Payer: WEA Trust Commercial |
$103.53
|
| Rate for Payer: WPS Commercial |
$139.42
|
|
|
IRRIGATING SLEEVE FOR PM2 58PM2SLV
|
Facility
|
OP
|
$5,632.00
|
|
| Hospital Charge Code |
6220208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,640.04 |
| Max. Negotiated Rate |
$5,388.70 |
| Rate for Payer: Aetna Commercial |
$5,271.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,037.26
|
| Rate for Payer: Aetna Managed Medicare |
$1,640.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,807.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,928.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,811.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,104.36
|
| Rate for Payer: Cash Price |
$1,689.60
|
| Rate for Payer: Cigna Commercial |
$5,388.70
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,277.82
|
| Rate for Payer: Health EOS Commercial |
$5,212.98
|
| Rate for Payer: HFN Commercial |
$5,388.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,392.96
|
| Rate for Payer: Multiplan Commercial |
$4,685.82
|
| Rate for Payer: NAPHCARE Commercial |
$3,514.37
|
| Rate for Payer: Preferred Network Access Commercial |
$5,388.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,870.07
|
| Rate for Payer: Quartz Commercial |
$3,807.23
|
| Rate for Payer: Quartz Medicare Advantage |
$3,514.37
|
| Rate for Payer: The Alliance Commercial |
$2,928.64
|
| Rate for Payer: WEA Trust Commercial |
$3,221.50
|
| Rate for Payer: WPS Commercial |
$4,338.33
|
|
|
IRRIGATING SLEEVE FOR PM2 58PM2SLV
|
Facility
|
IP
|
$5,632.00
|
|
| Hospital Charge Code |
6220208
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,870.07 |
| Max. Negotiated Rate |
$5,388.70 |
| Rate for Payer: Aetna Commercial |
$5,271.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$5,037.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,104.36
|
| Rate for Payer: Cash Price |
$1,689.60
|
| Rate for Payer: Cigna Commercial |
$5,388.70
|
| Rate for Payer: Health EOS Commercial |
$5,212.98
|
| Rate for Payer: HFN Commercial |
$5,388.70
|
| Rate for Payer: Multiplan Commercial |
$4,685.82
|
| Rate for Payer: Preferred Network Access Commercial |
$5,388.70
|
| Rate for Payer: Quartz Beloit One Network |
$2,870.07
|
| Rate for Payer: Quartz Commercial |
$3,514.37
|
| Rate for Payer: WEA Trust Commercial |
$3,221.50
|
| Rate for Payer: WPS Commercial |
$4,338.33
|
|
|
IRRIGATION, MAXILLARY SINUS 31000
|
Professional
|
Both
|
$359.00
|
|
|
Service Code
|
CPT 31000
|
| Hospital Charge Code |
3014367
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.25 |
| Max. Negotiated Rate |
$449.65 |
| Rate for Payer: Aetna Commercial |
$354.69
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.09
|
| Rate for Payer: Aetna Managed Medicare |
$99.92
|
| Rate for Payer: Anthem Medicare Advantage |
$99.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$99.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$99.92
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cash Price |
$107.70
|
| Rate for Payer: Cigna Commercial |
$354.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$71.25
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$99.92
|
| Rate for Payer: Health EOS Commercial |
$339.76
|
| Rate for Payer: HFN Commercial |
$354.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$372.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$372.15
|
| Rate for Payer: Independent Care Health Plan Medicare |
$99.92
|
| Rate for Payer: Multiplan Commercial |
$298.69
|
| Rate for Payer: NAPHCARE Commercial |
$149.88
|
| Rate for Payer: Preferred Network Access Commercial |
$354.69
|
| Rate for Payer: Quartz Beloit One Network |
$164.28
|
| Rate for Payer: Quartz Commercial |
$212.82
|
| Rate for Payer: Quartz Medicare Advantage |
$99.92
|
| Rate for Payer: The Alliance Commercial |
$424.67
|
| Rate for Payer: United Healthcare Medicaid |
$71.25
|
| Rate for Payer: United Healthcare Medicare Advantage |
$99.92
|
| Rate for Payer: WEA Trust Commercial |
$205.35
|
| Rate for Payer: WPS Commercial |
$449.65
|
|
|
IRRIGATION NEZHAT-DORSEY 5102710
|
Facility
|
IP
|
$952.00
|
|
| Hospital Charge Code |
2962952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$485.14 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$594.05
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
IRRIGATION NEZHAT-DORSEY 5102710
|
Facility
|
OP
|
$952.00
|
|
| Hospital Charge Code |
2962952
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.22 |
| Max. Negotiated Rate |
$910.87 |
| Rate for Payer: Aetna Commercial |
$891.07
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$851.47
|
| Rate for Payer: Aetna Managed Medicare |
$277.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$643.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$495.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$475.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$524.74
|
| Rate for Payer: Cash Price |
$285.60
|
| Rate for Payer: Cigna Commercial |
$910.87
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$554.06
|
| Rate for Payer: Health EOS Commercial |
$881.17
|
| Rate for Payer: HFN Commercial |
$910.87
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$742.56
|
| Rate for Payer: Multiplan Commercial |
$792.06
|
| Rate for Payer: NAPHCARE Commercial |
$594.05
|
| Rate for Payer: Preferred Network Access Commercial |
$910.87
|
| Rate for Payer: Quartz Beloit One Network |
$485.14
|
| Rate for Payer: Quartz Commercial |
$643.55
|
| Rate for Payer: Quartz Medicare Advantage |
$594.05
|
| Rate for Payer: The Alliance Commercial |
$495.04
|
| Rate for Payer: WEA Trust Commercial |
$544.54
|
| Rate for Payer: WPS Commercial |
$733.33
|
|
|
Irrigation of Bladder 51700PP
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
CPT 51700
|
| Hospital Charge Code |
3850017
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$414.96 |
| Rate for Payer: Aetna Commercial |
$414.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$375.65
|
| Rate for Payer: Aetna Managed Medicare |
$25.24
|
| Rate for Payer: Anthem Medicare Advantage |
$25.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.24
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: Cigna Commercial |
$414.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.24
|
| Rate for Payer: Health EOS Commercial |
$397.49
|
| Rate for Payer: HFN Commercial |
$414.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$105.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$105.62
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.24
|
| Rate for Payer: Multiplan Commercial |
$349.44
|
| Rate for Payer: NAPHCARE Commercial |
$37.86
|
| Rate for Payer: Preferred Network Access Commercial |
$414.96
|
| Rate for Payer: Quartz Beloit One Network |
$192.19
|
| Rate for Payer: Quartz Commercial |
$248.98
|
| Rate for Payer: Quartz Medicare Advantage |
$25.24
|
| Rate for Payer: The Alliance Commercial |
$107.27
|
| Rate for Payer: United Healthcare Medicaid |
$19.24
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.24
|
| Rate for Payer: WEA Trust Commercial |
$240.24
|
| Rate for Payer: WPS Commercial |
$113.58
|
|
|
Irrigation of Implanted Venous Access Device for Drug Delivery
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
3451575
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$101.92 |
| Max. Negotiated Rate |
$191.36 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$124.80
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
Irrigation of Implanted Venous Access Device for Drug Delivery
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
3451575
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$62.09 |
| Max. Negotiated Rate |
$248.35 |
| Rate for Payer: Aetna Commercial |
$187.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$178.88
|
| Rate for Payer: Aetna Managed Medicare |
$62.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$135.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$104.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$99.84
|
| Rate for Payer: Anthem Medicare Advantage |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$110.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$62.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$62.09
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$191.36
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$62.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$116.40
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$62.09
|
| Rate for Payer: Health EOS Commercial |
$185.12
|
| Rate for Payer: HFN Commercial |
$191.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$230.97
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.09
|
| Rate for Payer: Independent Care Health Plan Medicare |
$62.09
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$62.09
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$62.09
|
| Rate for Payer: Multiplan Commercial |
$166.40
|
| Rate for Payer: NAPHCARE Commercial |
$93.13
|
| Rate for Payer: Preferred Network Access Commercial |
$191.36
|
| Rate for Payer: Quartz Beloit One Network |
$101.92
|
| Rate for Payer: Quartz Commercial |
$135.20
|
| Rate for Payer: Quartz Medicare Advantage |
$62.09
|
| Rate for Payer: The Alliance Commercial |
$248.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$62.09
|
| Rate for Payer: United Healthcare PPO |
$156.00
|
| Rate for Payer: WEA Trust Commercial |
$114.40
|
| Rate for Payer: Wellcare Medicare |
$62.09
|
| Rate for Payer: WPS Commercial |
$154.06
|
|
|
IRRIGATOR HYDRO-SURG PLUS NEZHAT-DORSEY 0026870
|
Facility
|
IP
|
$839.00
|
|
| Hospital Charge Code |
5178939
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$427.55 |
| Max. Negotiated Rate |
$802.76 |
| Rate for Payer: Aetna Commercial |
$785.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$750.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$462.46
|
| Rate for Payer: Cash Price |
$251.70
|
| Rate for Payer: Cigna Commercial |
$802.76
|
| Rate for Payer: Health EOS Commercial |
$776.58
|
| Rate for Payer: HFN Commercial |
$802.76
|
| Rate for Payer: Multiplan Commercial |
$698.05
|
| Rate for Payer: Preferred Network Access Commercial |
$802.76
|
| Rate for Payer: Quartz Beloit One Network |
$427.55
|
| Rate for Payer: Quartz Commercial |
$523.54
|
| Rate for Payer: WEA Trust Commercial |
$479.91
|
| Rate for Payer: WPS Commercial |
$646.28
|
|
