|
ISNARE LARIAT SNARE BX00711084
|
Facility
|
IP
|
$4,309.00
|
|
| Hospital Charge Code |
5415807
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,111.41 |
| Max. Negotiated Rate |
$3,964.28 |
| Rate for Payer: Aetna Commercial |
$3,878.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,705.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,283.77
|
| Rate for Payer: Cash Price |
$1,292.70
|
| Rate for Payer: Cigna Commercial |
$3,964.28
|
| Rate for Payer: Health EOS Commercial |
$3,835.01
|
| Rate for Payer: HFN Commercial |
$3,964.28
|
| Rate for Payer: Multiplan Commercial |
$3,447.20
|
| Rate for Payer: NAPHCARE Commercial |
$2,585.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,964.28
|
| Rate for Payer: Quartz Beloit One Network |
$2,111.41
|
| Rate for Payer: Quartz Commercial |
$2,585.40
|
| Rate for Payer: WEA Trust Commercial |
$2,369.95
|
| Rate for Payer: WPS Commercial |
$3,191.68
|
|
|
Isoagglutinin Titer, Anti-B
|
Facility
|
OP
|
$747.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
5867634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$687.24 |
| Rate for Payer: Aetna Commercial |
$672.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.42
|
| Rate for Payer: Aetna Managed Medicare |
$168.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$633.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$295.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$280.24
|
| Rate for Payer: Anthem Medicaid |
$5.35
|
| Rate for Payer: Anthem Medicare Advantage |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$168.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$168.82
|
| Rate for Payer: Cash Price |
$224.10
|
| Rate for Payer: Cash Price |
$224.10
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$168.82
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5.35
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$418.02
|
| Rate for Payer: Dean Health Medicaid |
$5.35
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$168.82
|
| Rate for Payer: Health EOS Commercial |
$664.83
|
| Rate for Payer: HFN Commercial |
$687.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$628.01
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$168.82
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5.35
|
| Rate for Payer: Independent Care Health Plan Medicare |
$168.82
|
| Rate for Payer: Managed Health Services Medicaid |
$5.56
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$168.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$168.82
|
| Rate for Payer: Multiplan Commercial |
$597.60
|
| Rate for Payer: NAPHCARE Commercial |
$253.23
|
| Rate for Payer: Preferred Network Access Commercial |
$687.24
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5.35
|
| Rate for Payer: Quartz Beloit One Network |
$366.03
|
| Rate for Payer: Quartz Commercial |
$485.55
|
| Rate for Payer: Quartz Medicare Advantage |
$168.82
|
| Rate for Payer: The Alliance Commercial |
$675.28
|
| Rate for Payer: United Healthcare Medicaid |
$5.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$168.82
|
| Rate for Payer: United Healthcare PPO |
$560.25
|
| Rate for Payer: WEA Trust Commercial |
$410.85
|
| Rate for Payer: Wellcare Medicare |
$168.82
|
| Rate for Payer: WMAP Medicaid |
$5.35
|
| Rate for Payer: WPS Commercial |
$553.30
|
|
|
Isoagglutinin Titer, Anti-B
|
Facility
|
IP
|
$747.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
5867634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$366.03 |
| Max. Negotiated Rate |
$687.24 |
| Rate for Payer: Aetna Commercial |
$672.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$395.91
|
| Rate for Payer: Cash Price |
$224.10
|
| Rate for Payer: Cigna Commercial |
$687.24
|
| Rate for Payer: Health EOS Commercial |
$664.83
|
| Rate for Payer: HFN Commercial |
$687.24
|
| Rate for Payer: Multiplan Commercial |
$597.60
|
| Rate for Payer: NAPHCARE Commercial |
$448.20
|
| Rate for Payer: Preferred Network Access Commercial |
$687.24
|
| Rate for Payer: Quartz Beloit One Network |
$366.03
|
| Rate for Payer: Quartz Commercial |
$448.20
|
| Rate for Payer: WEA Trust Commercial |
$410.85
|
| Rate for Payer: WPS Commercial |
$553.30
|
|
|
Isoagglutinin Titer, Anti-B
|
Professional
|
Both
|
$747.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
5867634
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.29 |
| Max. Negotiated Rate |
$709.65 |
| Rate for Payer: Aetna Commercial |
$709.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$642.42
|
| Rate for Payer: Cash Price |
$224.10
|
| Rate for Payer: Cash Price |
$224.10
|
| Rate for Payer: Cigna Commercial |
$709.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$373.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$448.20
|
| Rate for Payer: Health EOS Commercial |
$679.77
|
| Rate for Payer: HFN Commercial |
$709.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18.29
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.29
|
| Rate for Payer: Multiplan Commercial |
$597.60
|
| Rate for Payer: Preferred Network Access Commercial |
$709.65
|
| Rate for Payer: Quartz Beloit One Network |
$328.68
|
| Rate for Payer: Quartz Commercial |
$425.79
|
| Rate for Payer: The Alliance Commercial |
$373.50
|
| Rate for Payer: WEA Trust Commercial |
$410.85
|
| Rate for Payer: WPS Commercial |
$553.30
|
|
|
Isodose Plan Complex
|
Facility
|
OP
|
$3,323.00
|
|
|
Service Code
|
CPT 77307
|
| Hospital Charge Code |
3040383
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$365.21 |
| Max. Negotiated Rate |
$3,057.16 |
| Rate for Payer: Aetna Commercial |
$2,990.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,857.78
|
| Rate for Payer: Aetna Managed Medicare |
$365.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,369.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,095.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.85
|
| Rate for Payer: Anthem Medicare Advantage |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,761.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$365.21
|
| Rate for Payer: Cash Price |
$996.90
|
| Rate for Payer: Cash Price |
$996.90
|
| Rate for Payer: Cigna Commercial |
$3,057.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$365.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,859.55
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$365.21
|
| Rate for Payer: Health EOS Commercial |
$2,957.47
|
| Rate for Payer: HFN Commercial |
$3,057.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,358.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$365.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$365.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$365.21
|
| Rate for Payer: Multiplan Commercial |
$2,658.40
|
| Rate for Payer: NAPHCARE Commercial |
$547.82
|
| Rate for Payer: Preferred Network Access Commercial |
$3,057.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,628.27
|
| Rate for Payer: Quartz Commercial |
$2,159.95
|
| Rate for Payer: Quartz Medicare Advantage |
$365.21
|
| Rate for Payer: The Alliance Commercial |
$1,460.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$365.21
|
| Rate for Payer: United Healthcare PPO |
$2,492.25
|
| Rate for Payer: WEA Trust Commercial |
$1,827.65
|
| Rate for Payer: Wellcare Medicare |
$365.21
|
| Rate for Payer: WPS Commercial |
$2,461.35
|
|
|
Isodose Plan Complex
|
Facility
|
IP
|
$3,323.00
|
|
|
Service Code
|
CPT 77307
|
| Hospital Charge Code |
3040383
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,628.27 |
| Max. Negotiated Rate |
$3,057.16 |
| Rate for Payer: Aetna Commercial |
$2,990.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,857.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,761.19
|
| Rate for Payer: Cash Price |
$996.90
|
| Rate for Payer: Cigna Commercial |
$3,057.16
|
| Rate for Payer: Health EOS Commercial |
$2,957.47
|
| Rate for Payer: HFN Commercial |
$3,057.16
|
| Rate for Payer: Multiplan Commercial |
$2,658.40
|
| Rate for Payer: NAPHCARE Commercial |
$1,993.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,057.16
|
| Rate for Payer: Quartz Beloit One Network |
$1,628.27
|
| Rate for Payer: Quartz Commercial |
$1,993.80
|
| Rate for Payer: WEA Trust Commercial |
$1,827.65
|
| Rate for Payer: WPS Commercial |
$2,461.35
|
|
|
Isodose Plan Simple
|
Facility
|
OP
|
$530.00
|
|
|
Service Code
|
CPT 77306
|
| Hospital Charge Code |
3040381
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$259.70 |
| Max. Negotiated Rate |
$1,460.84 |
| Rate for Payer: Aetna Commercial |
$477.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.80
|
| Rate for Payer: Aetna Managed Medicare |
$365.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,369.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,095.63
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,040.85
|
| Rate for Payer: Anthem Medicare Advantage |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$365.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$365.21
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$487.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$365.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$296.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$365.21
|
| Rate for Payer: Health EOS Commercial |
$471.70
|
| Rate for Payer: HFN Commercial |
$487.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,358.58
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$365.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$365.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$365.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$365.21
|
| Rate for Payer: Multiplan Commercial |
$424.00
|
| Rate for Payer: NAPHCARE Commercial |
$547.82
|
| Rate for Payer: Preferred Network Access Commercial |
$487.60
|
| Rate for Payer: Quartz Beloit One Network |
$259.70
|
| Rate for Payer: Quartz Commercial |
$344.50
|
| Rate for Payer: Quartz Medicare Advantage |
$365.21
|
| Rate for Payer: The Alliance Commercial |
$1,460.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$365.21
|
| Rate for Payer: United Healthcare PPO |
$397.50
|
| Rate for Payer: WEA Trust Commercial |
$291.50
|
| Rate for Payer: Wellcare Medicare |
$365.21
|
| Rate for Payer: WPS Commercial |
$392.57
|
|
|
Isodose Plan Simple
|
Facility
|
IP
|
$530.00
|
|
|
Service Code
|
CPT 77306
|
| Hospital Charge Code |
3040381
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$259.70 |
| Max. Negotiated Rate |
$487.60 |
| Rate for Payer: Aetna Commercial |
$477.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$455.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$280.90
|
| Rate for Payer: Cash Price |
$159.00
|
| Rate for Payer: Cigna Commercial |
$487.60
|
| Rate for Payer: Health EOS Commercial |
$471.70
|
| Rate for Payer: HFN Commercial |
$487.60
|
| Rate for Payer: Multiplan Commercial |
$424.00
|
| Rate for Payer: NAPHCARE Commercial |
$318.00
|
| Rate for Payer: Preferred Network Access Commercial |
$487.60
|
| Rate for Payer: Quartz Beloit One Network |
$259.70
|
| Rate for Payer: Quartz Commercial |
$318.00
|
| Rate for Payer: WEA Trust Commercial |
$291.50
|
| Rate for Payer: WPS Commercial |
$392.57
|
|
|
Isolation/Extraction Hi Pur Na
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation/Extraction Hi Pur Na
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation/Extraction Hi Pur Na
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation/Extraction Nuc Acid
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation/Extraction Nuc Acid
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation/Extraction Nuc Acid
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation Gowns
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040306
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
Isolation Gowns
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040306
|
|
Hospital Revenue Code
|
271
|
| 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: Cigna Commercial |
$0.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.56
|
| 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 |
$0.74
|
|
|
Isolation or Extraction
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation or Extraction
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation or Extraction
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation or Extraction of High
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation or Extraction of High
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Isolation or Extraction of High
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
ISO-NEB FILTERED NEBULIZER #1755
|
Facility
|
IP
|
$124.00
|
|
| Hospital Charge Code |
2974730
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$60.76 |
| Max. Negotiated Rate |
$114.08 |
| Rate for Payer: Aetna Commercial |
$111.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.72
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cigna Commercial |
$114.08
|
| Rate for Payer: Health EOS Commercial |
$110.36
|
| Rate for Payer: HFN Commercial |
$114.08
|
| Rate for Payer: Multiplan Commercial |
$99.20
|
| Rate for Payer: NAPHCARE Commercial |
$74.40
|
| Rate for Payer: Preferred Network Access Commercial |
$114.08
|
| Rate for Payer: Quartz Beloit One Network |
$60.76
|
| Rate for Payer: Quartz Commercial |
$74.40
|
| Rate for Payer: WEA Trust Commercial |
$68.20
|
| Rate for Payer: WPS Commercial |
$91.85
|
|
|
ISO-NEB FILTERED NEBULIZER #1755
|
Facility
|
OP
|
$124.00
|
|
| Hospital Charge Code |
2974730
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$34.72 |
| Max. Negotiated Rate |
$496.00 |
| Rate for Payer: Aetna Commercial |
$111.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$106.64
|
| Rate for Payer: Aetna Managed Medicare |
$34.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$80.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.72
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cigna Commercial |
$114.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.39
|
| Rate for Payer: Health EOS Commercial |
$110.36
|
| Rate for Payer: HFN Commercial |
$114.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.00
|
| Rate for Payer: Multiplan Commercial |
$99.20
|
| Rate for Payer: NAPHCARE Commercial |
$74.40
|
| Rate for Payer: Preferred Network Access Commercial |
$114.08
|
| Rate for Payer: Quartz Beloit One Network |
$60.76
|
| Rate for Payer: Quartz Commercial |
$80.60
|
| Rate for Payer: Quartz Medicare Advantage |
$74.40
|
| Rate for Payer: The Alliance Commercial |
$496.00
|
| Rate for Payer: WEA Trust Commercial |
$68.20
|
| Rate for Payer: WPS Commercial |
$91.85
|
|
|
ISTENT INJECT WITH 2 EYE STENTS G2W-US
|
Facility
|
IP
|
$11,380.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
5617638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,576.20 |
| Max. Negotiated Rate |
$10,469.60 |
| Rate for Payer: Aetna Commercial |
$10,242.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,786.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,031.40
|
| Rate for Payer: Cash Price |
$3,414.00
|
| Rate for Payer: Cigna Commercial |
$10,469.60
|
| Rate for Payer: Health EOS Commercial |
$10,128.20
|
| Rate for Payer: HFN Commercial |
$10,469.60
|
| Rate for Payer: Multiplan Commercial |
$9,104.00
|
| Rate for Payer: NAPHCARE Commercial |
$6,828.00
|
| Rate for Payer: Preferred Network Access Commercial |
$10,469.60
|
| Rate for Payer: Quartz Beloit One Network |
$5,576.20
|
| Rate for Payer: Quartz Commercial |
$6,828.00
|
| Rate for Payer: WEA Trust Commercial |
$6,259.00
|
| Rate for Payer: WPS Commercial |
$8,429.17
|
|
