|
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 |
$3,186.40 |
| Max. Negotiated Rate |
$45,520.00 |
| Rate for Payer: Aetna Commercial |
$10,242.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$9,786.80
|
| Rate for Payer: Aetna Managed Medicare |
$3,186.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,397.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,690.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5,462.40
|
| 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: Dean Health DHI/DHP/ASO |
$6,368.25
|
| Rate for Payer: Health EOS Commercial |
$10,128.20
|
| Rate for Payer: HFN Commercial |
$10,469.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$8,535.00
|
| 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 |
$7,397.00
|
| Rate for Payer: Quartz Medicare Advantage |
$6,828.00
|
| Rate for Payer: The Alliance Commercial |
$45,520.00
|
| Rate for Payer: WEA Trust Commercial |
$6,259.00
|
| Rate for Payer: WPS Commercial |
$8,429.17
|
|
|
Itraconazole Level
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna Commercial |
$265.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.94
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$265.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$139.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$167.40
|
| Rate for Payer: Health EOS Commercial |
$253.89
|
| Rate for Payer: HFN Commercial |
$265.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.80
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$65.80
|
| Rate for Payer: Multiplan Commercial |
$223.20
|
| Rate for Payer: Preferred Network Access Commercial |
$265.05
|
| Rate for Payer: Quartz Beloit One Network |
$122.76
|
| Rate for Payer: Quartz Commercial |
$159.03
|
| Rate for Payer: The Alliance Commercial |
$139.50
|
| Rate for Payer: WEA Trust Commercial |
$153.45
|
| Rate for Payer: WPS Commercial |
$206.66
|
|
|
Itraconazole Level
|
Facility
|
IP
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$136.71 |
| Max. Negotiated Rate |
$256.68 |
| Rate for Payer: Aetna Commercial |
$251.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.87
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$256.68
|
| Rate for Payer: Health EOS Commercial |
$248.31
|
| Rate for Payer: HFN Commercial |
$256.68
|
| Rate for Payer: Multiplan Commercial |
$223.20
|
| Rate for Payer: NAPHCARE Commercial |
$167.40
|
| Rate for Payer: Preferred Network Access Commercial |
$256.68
|
| Rate for Payer: Quartz Beloit One Network |
$136.71
|
| Rate for Payer: Quartz Commercial |
$167.40
|
| Rate for Payer: WEA Trust Commercial |
$153.45
|
| Rate for Payer: WPS Commercial |
$206.66
|
|
|
Itraconazole Level
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1040839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$256.68 |
| Rate for Payer: Aetna Commercial |
$251.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$239.94
|
| Rate for Payer: Aetna Managed Medicare |
$18.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$69.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.62
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.94
|
| Rate for Payer: Anthem Medicaid |
$19.26
|
| Rate for Payer: Anthem Medicare Advantage |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$147.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.64
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cash Price |
$83.70
|
| Rate for Payer: Cigna Commercial |
$256.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$19.26
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$156.13
|
| Rate for Payer: Dean Health Medicaid |
$19.26
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.64
|
| Rate for Payer: Health EOS Commercial |
$248.31
|
| Rate for Payer: HFN Commercial |
$256.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.34
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.64
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$19.26
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.64
|
| Rate for Payer: Managed Health Services Medicaid |
$20.03
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.64
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.64
|
| Rate for Payer: Multiplan Commercial |
$223.20
|
| Rate for Payer: NAPHCARE Commercial |
$27.96
|
| Rate for Payer: Preferred Network Access Commercial |
$256.68
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$19.26
|
| Rate for Payer: Quartz Beloit One Network |
$136.71
|
| Rate for Payer: Quartz Commercial |
$181.35
|
| Rate for Payer: Quartz Medicare Advantage |
$18.64
|
| Rate for Payer: The Alliance Commercial |
$74.56
|
| Rate for Payer: United Healthcare Medicaid |
$19.26
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.64
|
| Rate for Payer: United Healthcare PPO |
$209.25
|
| Rate for Payer: WEA Trust Commercial |
$153.45
|
| Rate for Payer: Wellcare Medicare |
$18.64
|
| Rate for Payer: WMAP Medicaid |
$19.26
|
| Rate for Payer: WPS Commercial |
$206.66
|
|
|
IVC Filter
|
Facility
|
OP
|
$8,972.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4139312
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,512.16 |
| Max. Negotiated Rate |
$35,888.00 |
| Rate for Payer: Aetna Commercial |
$8,074.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,715.92
|
| Rate for Payer: Aetna Managed Medicare |
$2,512.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,831.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,486.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,306.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,755.16
|
| Rate for Payer: Cash Price |
$2,691.60
|
| Rate for Payer: Cigna Commercial |
$8,254.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,020.73
|
| Rate for Payer: Health EOS Commercial |
$7,985.08
|
| Rate for Payer: HFN Commercial |
$8,254.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,729.00
|
| Rate for Payer: Multiplan Commercial |
$7,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,254.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,396.28
|
| Rate for Payer: Quartz Commercial |
$5,831.80
|
| Rate for Payer: Quartz Medicare Advantage |
$5,383.20
|
| Rate for Payer: The Alliance Commercial |
$35,888.00
|
| Rate for Payer: WEA Trust Commercial |
$4,934.60
|
| Rate for Payer: WPS Commercial |
$6,645.56
|
|
|
IVC Filter
|
Facility
|
IP
|
$8,972.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
4139312
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,396.28 |
| Max. Negotiated Rate |
$8,254.24 |
| Rate for Payer: Aetna Commercial |
$8,074.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,715.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,755.16
|
| Rate for Payer: Cash Price |
$2,691.60
|
| Rate for Payer: Cigna Commercial |
$8,254.24
|
| Rate for Payer: Health EOS Commercial |
$7,985.08
|
| Rate for Payer: HFN Commercial |
$8,254.24
|
| Rate for Payer: Multiplan Commercial |
$7,177.60
|
| Rate for Payer: NAPHCARE Commercial |
$5,383.20
|
| Rate for Payer: Preferred Network Access Commercial |
$8,254.24
|
| Rate for Payer: Quartz Beloit One Network |
$4,396.28
|
| Rate for Payer: Quartz Commercial |
$5,383.20
|
| Rate for Payer: WEA Trust Commercial |
$4,934.60
|
| Rate for Payer: WPS Commercial |
$6,645.56
|
|
|
IVC Filter Femoral
|
Facility
|
OP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.48 |
| Max. Negotiated Rate |
$40,264.00 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,542.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,831.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,632.93
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,549.50
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,542.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,039.60
|
| Rate for Payer: The Alliance Commercial |
$40,264.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IVC Filter Femoral
|
Facility
|
IP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,932.34 |
| Max. Negotiated Rate |
$9,260.72 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,039.60
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IVC Filter Femoral
|
Professional
|
Both
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,429.04 |
| Max. Negotiated Rate |
$9,562.70 |
| Rate for Payer: Aetna Commercial |
$9,562.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,562.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,033.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,039.60
|
| Rate for Payer: Health EOS Commercial |
$9,160.06
|
| Rate for Payer: HFN Commercial |
$9,562.70
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,562.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,429.04
|
| Rate for Payer: Quartz Commercial |
$5,737.62
|
| Rate for Payer: The Alliance Commercial |
$5,033.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IVC Filter Jugular
|
Facility
|
OP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,818.48 |
| Max. Negotiated Rate |
$40,264.00 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Aetna Managed Medicare |
$2,818.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,542.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,033.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,831.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,632.93
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,549.50
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,542.90
|
| Rate for Payer: Quartz Medicare Advantage |
$6,039.60
|
| Rate for Payer: The Alliance Commercial |
$40,264.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IVC Filter Jugular
|
Facility
|
IP
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,932.34 |
| Max. Negotiated Rate |
$9,260.72 |
| Rate for Payer: Aetna Commercial |
$9,059.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,334.98
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,260.72
|
| Rate for Payer: Health EOS Commercial |
$8,958.74
|
| Rate for Payer: HFN Commercial |
$9,260.72
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: NAPHCARE Commercial |
$6,039.60
|
| Rate for Payer: Preferred Network Access Commercial |
$9,260.72
|
| Rate for Payer: Quartz Beloit One Network |
$4,932.34
|
| Rate for Payer: Quartz Commercial |
$6,039.60
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IVC Filter Jugular
|
Professional
|
Both
|
$10,066.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
2550866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,429.04 |
| Max. Negotiated Rate |
$9,562.70 |
| Rate for Payer: Aetna Commercial |
$9,562.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,656.76
|
| Rate for Payer: Cash Price |
$3,019.80
|
| Rate for Payer: Cigna Commercial |
$9,562.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,033.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6,039.60
|
| Rate for Payer: Health EOS Commercial |
$9,160.06
|
| Rate for Payer: HFN Commercial |
$9,562.70
|
| Rate for Payer: Multiplan Commercial |
$8,052.80
|
| Rate for Payer: Preferred Network Access Commercial |
$9,562.70
|
| Rate for Payer: Quartz Beloit One Network |
$4,429.04
|
| Rate for Payer: Quartz Commercial |
$5,737.62
|
| Rate for Payer: The Alliance Commercial |
$5,033.00
|
| Rate for Payer: WEA Trust Commercial |
$5,536.30
|
| Rate for Payer: WPS Commercial |
$7,455.89
|
|
|
IV Hydration 1 hour
|
Facility
|
OP
|
$431.00
|
|
| Hospital Charge Code |
1158866
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$120.68 |
| Max. Negotiated Rate |
$1,724.00 |
| Rate for Payer: Aetna Commercial |
$387.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.66
|
| Rate for Payer: Aetna Managed Medicare |
$120.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$280.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$215.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$206.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.43
|
| Rate for Payer: Cash Price |
$129.30
|
| Rate for Payer: Cigna Commercial |
$396.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$241.19
|
| Rate for Payer: Health EOS Commercial |
$383.59
|
| Rate for Payer: HFN Commercial |
$396.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$323.25
|
| Rate for Payer: Multiplan Commercial |
$344.80
|
| Rate for Payer: NAPHCARE Commercial |
$258.60
|
| Rate for Payer: Preferred Network Access Commercial |
$396.52
|
| Rate for Payer: Quartz Beloit One Network |
$211.19
|
| Rate for Payer: Quartz Commercial |
$280.15
|
| Rate for Payer: Quartz Medicare Advantage |
$258.60
|
| Rate for Payer: The Alliance Commercial |
$1,724.00
|
| Rate for Payer: United Healthcare PPO |
$323.25
|
| Rate for Payer: WEA Trust Commercial |
$237.05
|
| Rate for Payer: WPS Commercial |
$319.24
|
|
|
IV Hydration 1 hour
|
Professional
|
Both
|
$431.00
|
|
| Hospital Charge Code |
1158866
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$189.64 |
| Max. Negotiated Rate |
$409.45 |
| Rate for Payer: Aetna Commercial |
$409.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.66
|
| Rate for Payer: Cash Price |
$129.30
|
| Rate for Payer: Cigna Commercial |
$409.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$215.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$258.60
|
| Rate for Payer: Health EOS Commercial |
$392.21
|
| Rate for Payer: HFN Commercial |
$409.45
|
| Rate for Payer: Multiplan Commercial |
$344.80
|
| Rate for Payer: Preferred Network Access Commercial |
$409.45
|
| Rate for Payer: Quartz Beloit One Network |
$189.64
|
| Rate for Payer: Quartz Commercial |
$245.67
|
| Rate for Payer: The Alliance Commercial |
$215.50
|
| Rate for Payer: WEA Trust Commercial |
$237.05
|
| Rate for Payer: WPS Commercial |
$319.24
|
|
|
IV Hydration 1 hour
|
Facility
|
IP
|
$431.00
|
|
| Hospital Charge Code |
1158866
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$211.19 |
| Max. Negotiated Rate |
$396.52 |
| Rate for Payer: Aetna Commercial |
$387.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$370.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$228.43
|
| Rate for Payer: Cash Price |
$129.30
|
| Rate for Payer: Cigna Commercial |
$396.52
|
| Rate for Payer: Health EOS Commercial |
$383.59
|
| Rate for Payer: HFN Commercial |
$396.52
|
| Rate for Payer: Multiplan Commercial |
$344.80
|
| Rate for Payer: NAPHCARE Commercial |
$258.60
|
| Rate for Payer: Preferred Network Access Commercial |
$396.52
|
| Rate for Payer: Quartz Beloit One Network |
$211.19
|
| Rate for Payer: Quartz Commercial |
$258.60
|
| Rate for Payer: WEA Trust Commercial |
$237.05
|
| Rate for Payer: WPS Commercial |
$319.24
|
|
|
IV Infusion For Hydration 1 Hr
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
3040216
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$303.80 |
| Max. Negotiated Rate |
$570.40 |
| Rate for Payer: Aetna Commercial |
$558.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.60
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$570.40
|
| Rate for Payer: Health EOS Commercial |
$551.80
|
| Rate for Payer: HFN Commercial |
$570.40
|
| Rate for Payer: Multiplan Commercial |
$496.00
|
| Rate for Payer: NAPHCARE Commercial |
$372.00
|
| Rate for Payer: Preferred Network Access Commercial |
$570.40
|
| Rate for Payer: Quartz Beloit One Network |
$303.80
|
| Rate for Payer: Quartz Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$341.00
|
| Rate for Payer: WPS Commercial |
$459.23
|
|
|
IV Infusion For Hydration 1 Hr
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
3040216
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$211.85 |
| Max. Negotiated Rate |
$847.40 |
| Rate for Payer: Aetna Commercial |
$558.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.20
|
| Rate for Payer: Aetna Managed Medicare |
$211.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$403.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$310.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.60
|
| Rate for Payer: Anthem Medicare Advantage |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.85
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$570.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.85
|
| Rate for Payer: Health EOS Commercial |
$551.80
|
| Rate for Payer: HFN Commercial |
$570.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$788.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.85
|
| Rate for Payer: Multiplan Commercial |
$496.00
|
| Rate for Payer: NAPHCARE Commercial |
$317.78
|
| Rate for Payer: Preferred Network Access Commercial |
$570.40
|
| Rate for Payer: Quartz Beloit One Network |
$303.80
|
| Rate for Payer: Quartz Commercial |
$403.00
|
| Rate for Payer: Quartz Medicare Advantage |
$211.85
|
| Rate for Payer: The Alliance Commercial |
$847.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.85
|
| Rate for Payer: United Healthcare PPO |
$465.00
|
| Rate for Payer: WEA Trust Commercial |
$341.00
|
| Rate for Payer: Wellcare Medicare |
$211.85
|
| Rate for Payer: WPS Commercial |
$459.23
|
|
|
IV Infusion for Hydration 1 HR - 96360
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
5516703
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$303.80 |
| Max. Negotiated Rate |
$570.40 |
| Rate for Payer: Aetna Commercial |
$558.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.60
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$570.40
|
| Rate for Payer: Health EOS Commercial |
$551.80
|
| Rate for Payer: HFN Commercial |
$570.40
|
| Rate for Payer: Multiplan Commercial |
$496.00
|
| Rate for Payer: NAPHCARE Commercial |
$372.00
|
| Rate for Payer: Preferred Network Access Commercial |
$570.40
|
| Rate for Payer: Quartz Beloit One Network |
$303.80
|
| Rate for Payer: Quartz Commercial |
$372.00
|
| Rate for Payer: WEA Trust Commercial |
$341.00
|
| Rate for Payer: WPS Commercial |
$459.23
|
|
|
IV Infusion for Hydration 1 HR - 96360
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
5516703
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$211.85 |
| Max. Negotiated Rate |
$847.40 |
| Rate for Payer: Aetna Commercial |
$558.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$533.20
|
| Rate for Payer: Aetna Managed Medicare |
$211.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$403.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$310.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.60
|
| Rate for Payer: Anthem Medicare Advantage |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.85
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$570.40
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$346.95
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.85
|
| Rate for Payer: Health EOS Commercial |
$551.80
|
| Rate for Payer: HFN Commercial |
$570.40
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$788.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.85
|
| Rate for Payer: Multiplan Commercial |
$496.00
|
| Rate for Payer: NAPHCARE Commercial |
$317.78
|
| Rate for Payer: Preferred Network Access Commercial |
$570.40
|
| Rate for Payer: Quartz Beloit One Network |
$303.80
|
| Rate for Payer: Quartz Commercial |
$403.00
|
| Rate for Payer: Quartz Medicare Advantage |
$211.85
|
| Rate for Payer: The Alliance Commercial |
$847.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.85
|
| Rate for Payer: United Healthcare PPO |
$465.00
|
| Rate for Payer: WEA Trust Commercial |
$341.00
|
| Rate for Payer: Wellcare Medicare |
$211.85
|
| Rate for Payer: WPS Commercial |
$459.23
|
|
|
IV Infusion for Hydration Add HR - 96361
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
5516704
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$135.24 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$165.60
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$165.60
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
IV Infusion for Hydration Add HR - 96361
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
5516704
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$46.95 |
| Max. Negotiated Rate |
$253.92 |
| Rate for Payer: Aetna Commercial |
$248.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$237.36
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$179.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$138.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$132.48
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$146.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.95
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$253.92
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$154.45
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$245.64
|
| Rate for Payer: HFN Commercial |
$253.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$174.65
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$46.95
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.95
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$46.95
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$46.95
|
| Rate for Payer: Multiplan Commercial |
$220.80
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$253.92
|
| Rate for Payer: Quartz Beloit One Network |
$135.24
|
| Rate for Payer: Quartz Commercial |
$179.40
|
| Rate for Payer: Quartz Medicare Advantage |
$46.95
|
| Rate for Payer: The Alliance Commercial |
$187.80
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.95
|
| Rate for Payer: United Healthcare PPO |
$207.00
|
| Rate for Payer: WEA Trust Commercial |
$151.80
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$204.43
|
|
|
IV Infusion For Therapy 1 Hour
|
Facility
|
IP
|
$622.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
3040219
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$304.78 |
| Max. Negotiated Rate |
$572.24 |
| Rate for Payer: Aetna Commercial |
$559.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$534.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.66
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cigna Commercial |
$572.24
|
| Rate for Payer: Health EOS Commercial |
$553.58
|
| Rate for Payer: HFN Commercial |
$572.24
|
| Rate for Payer: Multiplan Commercial |
$497.60
|
| Rate for Payer: NAPHCARE Commercial |
$373.20
|
| Rate for Payer: Preferred Network Access Commercial |
$572.24
|
| Rate for Payer: Quartz Beloit One Network |
$304.78
|
| Rate for Payer: Quartz Commercial |
$373.20
|
| Rate for Payer: WEA Trust Commercial |
$342.10
|
| Rate for Payer: WPS Commercial |
$460.72
|
|
|
IV Infusion For Therapy 1 Hour
|
Facility
|
OP
|
$622.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
3040219
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$211.85 |
| Max. Negotiated Rate |
$847.40 |
| Rate for Payer: Aetna Commercial |
$559.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$534.92
|
| Rate for Payer: Aetna Managed Medicare |
$211.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$404.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$311.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$298.56
|
| Rate for Payer: Anthem Medicare Advantage |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.85
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cigna Commercial |
$572.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.85
|
| Rate for Payer: Health EOS Commercial |
$553.58
|
| Rate for Payer: HFN Commercial |
$572.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$788.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.85
|
| Rate for Payer: Multiplan Commercial |
$497.60
|
| Rate for Payer: NAPHCARE Commercial |
$317.78
|
| Rate for Payer: Preferred Network Access Commercial |
$572.24
|
| Rate for Payer: Quartz Beloit One Network |
$304.78
|
| Rate for Payer: Quartz Commercial |
$404.30
|
| Rate for Payer: Quartz Medicare Advantage |
$211.85
|
| Rate for Payer: The Alliance Commercial |
$847.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.85
|
| Rate for Payer: United Healthcare PPO |
$466.50
|
| Rate for Payer: WEA Trust Commercial |
$342.10
|
| Rate for Payer: Wellcare Medicare |
$211.85
|
| Rate for Payer: WPS Commercial |
$460.72
|
|
|
IV Infusion For Therapy 1 HR - 96365
|
Facility
|
IP
|
$622.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
5516705
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$304.78 |
| Max. Negotiated Rate |
$572.24 |
| Rate for Payer: Aetna Commercial |
$559.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$534.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.66
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cigna Commercial |
$572.24
|
| Rate for Payer: Health EOS Commercial |
$553.58
|
| Rate for Payer: HFN Commercial |
$572.24
|
| Rate for Payer: Multiplan Commercial |
$497.60
|
| Rate for Payer: NAPHCARE Commercial |
$373.20
|
| Rate for Payer: Preferred Network Access Commercial |
$572.24
|
| Rate for Payer: Quartz Beloit One Network |
$304.78
|
| Rate for Payer: Quartz Commercial |
$373.20
|
| Rate for Payer: WEA Trust Commercial |
$342.10
|
| Rate for Payer: WPS Commercial |
$460.72
|
|
|
IV Infusion For Therapy 1 HR - 96365
|
Facility
|
OP
|
$622.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
5516705
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$211.85 |
| Max. Negotiated Rate |
$847.40 |
| Rate for Payer: Aetna Commercial |
$559.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$534.92
|
| Rate for Payer: Aetna Managed Medicare |
$211.85
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$404.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$311.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$298.56
|
| Rate for Payer: Anthem Medicare Advantage |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$329.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$211.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$211.85
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cash Price |
$186.60
|
| Rate for Payer: Cigna Commercial |
$572.24
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$211.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$348.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$211.85
|
| Rate for Payer: Health EOS Commercial |
$553.58
|
| Rate for Payer: HFN Commercial |
$572.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$788.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$211.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$211.85
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$211.85
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$211.85
|
| Rate for Payer: Multiplan Commercial |
$497.60
|
| Rate for Payer: NAPHCARE Commercial |
$317.78
|
| Rate for Payer: Preferred Network Access Commercial |
$572.24
|
| Rate for Payer: Quartz Beloit One Network |
$304.78
|
| Rate for Payer: Quartz Commercial |
$404.30
|
| Rate for Payer: Quartz Medicare Advantage |
$211.85
|
| Rate for Payer: The Alliance Commercial |
$847.40
|
| Rate for Payer: United Healthcare Medicare Advantage |
$211.85
|
| Rate for Payer: United Healthcare PPO |
$466.50
|
| Rate for Payer: WEA Trust Commercial |
$342.10
|
| Rate for Payer: Wellcare Medicare |
$211.85
|
| Rate for Payer: WPS Commercial |
$460.72
|
|
