|
Isolation/Extraction Hi Pur Na
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation/Extraction Hi Pur Na
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776825
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation/Extraction Nuc Acid
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation/Extraction Nuc Acid
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation/Extraction Nuc Acid
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776826
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.30
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation Gowns
|
Facility
|
OP
|
$1.00
|
|
| Hospital Charge Code |
3040306
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.96 |
| 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: Cigna Commercial |
$0.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.58
|
| 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 |
$0.52
|
| Rate for Payer: WEA Trust Commercial |
$0.57
|
| Rate for Payer: WPS Commercial |
$0.77
|
|
|
Isolation Gowns
|
Facility
|
IP
|
$1.00
|
|
| Hospital Charge Code |
3040306
|
|
Hospital Revenue Code
|
271
|
| 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
|
|
|
Isolation or Extraction
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation or Extraction
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.30
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation or Extraction
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776823
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation or Extraction of High
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.15 |
| Max. Negotiated Rate |
$78.05 |
| Rate for Payer: Aetna Commercial |
$78.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$78.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$41.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$49.30
|
| Rate for Payer: Health EOS Commercial |
$74.77
|
| Rate for Payer: HFN Commercial |
$78.05
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$78.05
|
| Rate for Payer: Quartz Beloit One Network |
$36.15
|
| Rate for Payer: Quartz Commercial |
$46.83
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation or Extraction of High
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$23.00 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Aetna Managed Medicare |
$23.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.98
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.62
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: NAPHCARE Commercial |
$49.30
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$53.40
|
| Rate for Payer: Quartz Medicare Advantage |
$49.30
|
| Rate for Payer: The Alliance Commercial |
$41.08
|
| Rate for Payer: United Healthcare PPO |
$61.62
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
Isolation or Extraction of High
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776824
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$75.59 |
| Rate for Payer: Aetna Commercial |
$73.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.54
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.59
|
| Rate for Payer: Health EOS Commercial |
$73.12
|
| Rate for Payer: HFN Commercial |
$75.59
|
| Rate for Payer: Multiplan Commercial |
$65.73
|
| Rate for Payer: Preferred Network Access Commercial |
$75.59
|
| Rate for Payer: Quartz Beloit One Network |
$40.26
|
| Rate for Payer: Quartz Commercial |
$49.30
|
| Rate for Payer: WEA Trust Commercial |
$45.19
|
| Rate for Payer: WPS Commercial |
$60.85
|
|
|
ISO-NEB FILTERED NEBULIZER #1755
|
Facility
|
IP
|
$124.00
|
|
| Hospital Charge Code |
2974730
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$63.19 |
| Max. Negotiated Rate |
$118.64 |
| Rate for Payer: Aetna Commercial |
$116.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.35
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cigna Commercial |
$118.64
|
| Rate for Payer: Health EOS Commercial |
$114.77
|
| Rate for Payer: HFN Commercial |
$118.64
|
| Rate for Payer: Multiplan Commercial |
$103.17
|
| Rate for Payer: Preferred Network Access Commercial |
$118.64
|
| Rate for Payer: Quartz Beloit One Network |
$63.19
|
| Rate for Payer: Quartz Commercial |
$77.38
|
| Rate for Payer: WEA Trust Commercial |
$70.93
|
| Rate for Payer: WPS Commercial |
$95.52
|
|
|
ISO-NEB FILTERED NEBULIZER #1755
|
Facility
|
OP
|
$124.00
|
|
| Hospital Charge Code |
2974730
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$36.11 |
| Max. Negotiated Rate |
$118.64 |
| Rate for Payer: Aetna Commercial |
$116.06
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$110.91
|
| Rate for Payer: Aetna Managed Medicare |
$36.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$83.82
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$64.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$61.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$68.35
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cigna Commercial |
$118.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$72.17
|
| Rate for Payer: Health EOS Commercial |
$114.77
|
| Rate for Payer: HFN Commercial |
$118.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$96.72
|
| Rate for Payer: Multiplan Commercial |
$103.17
|
| Rate for Payer: NAPHCARE Commercial |
$77.38
|
| Rate for Payer: Preferred Network Access Commercial |
$118.64
|
| Rate for Payer: Quartz Beloit One Network |
$63.19
|
| Rate for Payer: Quartz Commercial |
$83.82
|
| Rate for Payer: Quartz Medicare Advantage |
$77.38
|
| Rate for Payer: The Alliance Commercial |
$64.48
|
| Rate for Payer: WEA Trust Commercial |
$70.93
|
| Rate for Payer: WPS Commercial |
$95.52
|
|
|
ISTENT INJECT WITH 2 EYE STENTS G2W-US
|
Facility
|
OP
|
$11,380.00
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
5617638
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,313.86 |
| Max. Negotiated Rate |
$10,888.38 |
| Rate for Payer: Aetna Commercial |
$10,651.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,178.27
|
| Rate for Payer: Aetna Managed Medicare |
$3,313.86
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,692.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,917.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,680.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,272.66
|
| Rate for Payer: Cash Price |
$3,414.00
|
| Rate for Payer: Cigna Commercial |
$10,888.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,623.16
|
| Rate for Payer: Health EOS Commercial |
$10,533.33
|
| Rate for Payer: HFN Commercial |
$10,888.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,876.40
|
| Rate for Payer: Multiplan Commercial |
$9,468.16
|
| Rate for Payer: NAPHCARE Commercial |
$7,101.12
|
| Rate for Payer: Preferred Network Access Commercial |
$10,888.38
|
| Rate for Payer: Quartz Beloit One Network |
$5,799.25
|
| Rate for Payer: Quartz Commercial |
$7,692.88
|
| Rate for Payer: Quartz Medicare Advantage |
$7,101.12
|
| Rate for Payer: The Alliance Commercial |
$5,917.60
|
| Rate for Payer: WEA Trust Commercial |
$6,509.36
|
| Rate for Payer: WPS Commercial |
$8,766.01
|
|
|
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 |
$5,799.25 |
| Max. Negotiated Rate |
$10,888.38 |
| Rate for Payer: Aetna Commercial |
$10,651.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10,178.27
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6,272.66
|
| Rate for Payer: Cash Price |
$3,414.00
|
| Rate for Payer: Cigna Commercial |
$10,888.38
|
| Rate for Payer: Health EOS Commercial |
$10,533.33
|
| Rate for Payer: HFN Commercial |
$10,888.38
|
| Rate for Payer: Multiplan Commercial |
$9,468.16
|
| Rate for Payer: Preferred Network Access Commercial |
$10,888.38
|
| Rate for Payer: Quartz Beloit One Network |
$5,799.25
|
| Rate for Payer: Quartz Commercial |
$7,101.12
|
| Rate for Payer: WEA Trust Commercial |
$6,509.36
|
| Rate for Payer: WPS Commercial |
$8,766.01
|
|
|
Itraconazole Level
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$275.65 |
| Rate for Payer: Aetna Commercial |
$275.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$275.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$264.05
|
| Rate for Payer: HFN Commercial |
$275.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$68.43
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$68.43
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$275.65
|
| Rate for Payer: Quartz Beloit One Network |
$127.67
|
| Rate for Payer: Quartz Commercial |
$165.39
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$76.57
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$85.30
|
|
|
Itraconazole Level
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Aetna Managed Medicare |
$19.39
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$72.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.92
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.18
|
| Rate for Payer: Anthem Medicare Advantage |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$19.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$19.39
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$19.39
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.38
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$19.39
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$72.11
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$19.39
|
| Rate for Payer: Independent Care Health Plan Medicare |
$19.39
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$19.39
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$19.39
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: NAPHCARE Commercial |
$29.08
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$188.60
|
| Rate for Payer: Quartz Medicare Advantage |
$19.39
|
| Rate for Payer: The Alliance Commercial |
$77.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$19.39
|
| Rate for Payer: United Healthcare PPO |
$217.62
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: Wellcare Medicare |
$19.39
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
Itraconazole Level
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$142.18 |
| Max. Negotiated Rate |
$266.95 |
| Rate for Payer: Aetna Commercial |
$261.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$249.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$153.78
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$266.95
|
| Rate for Payer: Health EOS Commercial |
$258.24
|
| Rate for Payer: HFN Commercial |
$266.95
|
| Rate for Payer: Multiplan Commercial |
$232.13
|
| Rate for Payer: Preferred Network Access Commercial |
$266.95
|
| Rate for Payer: Quartz Beloit One Network |
$142.18
|
| Rate for Payer: Quartz Commercial |
$174.10
|
| Rate for Payer: WEA Trust Commercial |
$159.59
|
| Rate for Payer: WPS Commercial |
$214.91
|
|
|
IVC Filter
|
Facility
|
IP
|
$8,972.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4139312
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,572.13 |
| Max. Negotiated Rate |
$8,584.41 |
| Rate for Payer: Aetna Commercial |
$8,397.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,024.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,945.37
|
| Rate for Payer: Cash Price |
$2,691.60
|
| Rate for Payer: Cigna Commercial |
$8,584.41
|
| Rate for Payer: Health EOS Commercial |
$8,304.48
|
| Rate for Payer: HFN Commercial |
$8,584.41
|
| Rate for Payer: Multiplan Commercial |
$7,464.70
|
| Rate for Payer: Preferred Network Access Commercial |
$8,584.41
|
| Rate for Payer: Quartz Beloit One Network |
$4,572.13
|
| Rate for Payer: Quartz Commercial |
$5,598.53
|
| Rate for Payer: WEA Trust Commercial |
$5,131.98
|
| Rate for Payer: WPS Commercial |
$6,911.13
|
|
|
IVC Filter
|
Facility
|
OP
|
$8,972.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4139312
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,612.65 |
| Max. Negotiated Rate |
$8,584.41 |
| Rate for Payer: Aetna Commercial |
$8,397.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,024.56
|
| Rate for Payer: Aetna Managed Medicare |
$2,612.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,065.07
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,665.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,478.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,945.37
|
| Rate for Payer: Cash Price |
$2,691.60
|
| Rate for Payer: Cigna Commercial |
$8,584.41
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,221.70
|
| Rate for Payer: Health EOS Commercial |
$8,304.48
|
| Rate for Payer: HFN Commercial |
$8,584.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,998.16
|
| Rate for Payer: Multiplan Commercial |
$7,464.70
|
| Rate for Payer: NAPHCARE Commercial |
$5,598.53
|
| Rate for Payer: Preferred Network Access Commercial |
$8,584.41
|
| Rate for Payer: Quartz Beloit One Network |
$4,572.13
|
| Rate for Payer: Quartz Commercial |
$6,065.07
|
| Rate for Payer: Quartz Medicare Advantage |
$5,598.53
|
| Rate for Payer: The Alliance Commercial |
$4,665.44
|
| Rate for Payer: WEA Trust Commercial |
$5,131.98
|
| Rate for Payer: WPS Commercial |
$6,911.13
|
|
|
IVC Filter Femoral
|
Professional
|
Both
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,606.20 |
| Max. Negotiated Rate |
$9,945.21 |
| Rate for Payer: Aetna Commercial |
$9,945.21
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.03
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,945.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,234.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,281.18
|
| Rate for Payer: Health EOS Commercial |
$9,526.46
|
| Rate for Payer: HFN Commercial |
$9,945.21
|
| Rate for Payer: Multiplan Commercial |
$8,374.91
|
| Rate for Payer: Preferred Network Access Commercial |
$9,945.21
|
| Rate for Payer: Quartz Beloit One Network |
$4,606.20
|
| Rate for Payer: Quartz Commercial |
$5,967.12
|
| Rate for Payer: The Alliance Commercial |
$5,234.32
|
| Rate for Payer: WEA Trust Commercial |
$5,757.75
|
| Rate for Payer: WPS Commercial |
$7,753.84
|
|
|
IVC Filter Femoral
|
Facility
|
IP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,129.63 |
| Max. Negotiated Rate |
$9,631.15 |
| Rate for Payer: Aetna Commercial |
$9,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.38
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,631.15
|
| Rate for Payer: Health EOS Commercial |
$9,317.09
|
| Rate for Payer: HFN Commercial |
$9,631.15
|
| Rate for Payer: Multiplan Commercial |
$8,374.91
|
| Rate for Payer: Preferred Network Access Commercial |
$9,631.15
|
| Rate for Payer: Quartz Beloit One Network |
$5,129.63
|
| Rate for Payer: Quartz Commercial |
$6,281.18
|
| Rate for Payer: WEA Trust Commercial |
$5,757.75
|
| Rate for Payer: WPS Commercial |
$7,753.84
|
|
|
IVC Filter Femoral
|
Facility
|
OP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,931.22 |
| Max. Negotiated Rate |
$9,631.15 |
| Rate for Payer: Aetna Commercial |
$9,421.78
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,003.03
|
| Rate for Payer: Aetna Managed Medicare |
$2,931.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,804.62
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,234.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,024.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,548.38
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,631.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,858.41
|
| Rate for Payer: Health EOS Commercial |
$9,317.09
|
| Rate for Payer: HFN Commercial |
$9,631.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,851.48
|
| Rate for Payer: Multiplan Commercial |
$8,374.91
|
| Rate for Payer: NAPHCARE Commercial |
$6,281.18
|
| Rate for Payer: Preferred Network Access Commercial |
$9,631.15
|
| Rate for Payer: Quartz Beloit One Network |
$5,129.63
|
| Rate for Payer: Quartz Commercial |
$6,804.62
|
| Rate for Payer: Quartz Medicare Advantage |
$6,281.18
|
| Rate for Payer: The Alliance Commercial |
$5,234.32
|
| Rate for Payer: WEA Trust Commercial |
$5,757.75
|
| Rate for Payer: WPS Commercial |
$7,753.84
|
|
