|
IV Infusion Hydration Addl hr
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
3970749
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
IV Infusion Hydration Addl HR
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
4532709
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$96.31 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$117.94
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
IV Infusion Hydration Addl HR
|
Facility
|
OP
|
$189.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
4532709
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$176.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$169.04
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$127.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$98.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$94.35
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$104.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: Cigna Commercial |
$180.84
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$110.00
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$174.94
|
| Rate for Payer: HFN Commercial |
$180.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$157.25
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$180.84
|
| Rate for Payer: Quartz Beloit One Network |
$96.31
|
| Rate for Payer: Quartz Commercial |
$127.76
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$147.42
|
| Rate for Payer: WEA Trust Commercial |
$108.11
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$145.59
|
|
|
IV Infusion Therapy Ea Addl Hr
|
Facility
|
IP
|
$264.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
3040218
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$134.53 |
| Max. Negotiated Rate |
$252.60 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.52
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$252.60
|
| Rate for Payer: Health EOS Commercial |
$244.36
|
| Rate for Payer: HFN Commercial |
$252.60
|
| Rate for Payer: Multiplan Commercial |
$219.65
|
| Rate for Payer: Preferred Network Access Commercial |
$252.60
|
| Rate for Payer: Quartz Beloit One Network |
$134.53
|
| Rate for Payer: Quartz Commercial |
$164.74
|
| Rate for Payer: WEA Trust Commercial |
$151.01
|
| Rate for Payer: WPS Commercial |
$203.36
|
|
|
IV Infusion Therapy Ea Addl Hr
|
Facility
|
OP
|
$264.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
3040218
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$252.60 |
| Rate for Payer: Aetna Commercial |
$247.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$236.12
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$178.46
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$137.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$131.79
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$145.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cash Price |
$79.20
|
| Rate for Payer: Cigna Commercial |
$252.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$153.65
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$244.36
|
| Rate for Payer: HFN Commercial |
$252.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$219.65
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$252.60
|
| Rate for Payer: Quartz Beloit One Network |
$134.53
|
| Rate for Payer: Quartz Commercial |
$178.46
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$205.92
|
| Rate for Payer: WEA Trust Commercial |
$151.01
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$203.36
|
|
|
IV Infuson For Hydration Add Hr
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
3040217
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$186.58
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$143.52
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$137.78
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$49.28
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$160.63
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$49.28
|
| Rate for Payer: Independent Care Health Plan Medicare |
$49.28
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$49.28
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$49.28
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$186.58
|
| Rate for Payer: Quartz Medicare Advantage |
$49.28
|
| Rate for Payer: The Alliance Commercial |
$197.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$49.28
|
| Rate for Payer: United Healthcare PPO |
$215.28
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
IV Infuson For Hydration Add Hr
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
3040217
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$140.65 |
| Max. Negotiated Rate |
$264.08 |
| Rate for Payer: Aetna Commercial |
$258.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$246.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$152.13
|
| Rate for Payer: Cash Price |
$82.80
|
| Rate for Payer: Cigna Commercial |
$264.08
|
| Rate for Payer: Health EOS Commercial |
$255.47
|
| Rate for Payer: HFN Commercial |
$264.08
|
| Rate for Payer: Multiplan Commercial |
$229.63
|
| Rate for Payer: Preferred Network Access Commercial |
$264.08
|
| Rate for Payer: Quartz Beloit One Network |
$140.65
|
| Rate for Payer: Quartz Commercial |
$172.22
|
| Rate for Payer: WEA Trust Commercial |
$157.87
|
| Rate for Payer: WPS Commercial |
$212.60
|
|
|
IV PUMP
|
Facility
|
IP
|
$579.00
|
|
| Hospital Charge Code |
3075868
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$295.06 |
| Max. Negotiated Rate |
$553.99 |
| Rate for Payer: Aetna Commercial |
$541.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.14
|
| Rate for Payer: Cash Price |
$173.70
|
| Rate for Payer: Cigna Commercial |
$553.99
|
| Rate for Payer: Health EOS Commercial |
$535.92
|
| Rate for Payer: HFN Commercial |
$553.99
|
| Rate for Payer: Multiplan Commercial |
$481.73
|
| Rate for Payer: Preferred Network Access Commercial |
$553.99
|
| Rate for Payer: Quartz Beloit One Network |
$295.06
|
| Rate for Payer: Quartz Commercial |
$361.30
|
| Rate for Payer: WEA Trust Commercial |
$331.19
|
| Rate for Payer: WPS Commercial |
$446.00
|
|
|
IV PUMP
|
Facility
|
OP
|
$579.00
|
|
| Hospital Charge Code |
3075868
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$168.60 |
| Max. Negotiated Rate |
$553.99 |
| Rate for Payer: Aetna Commercial |
$541.94
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$517.86
|
| Rate for Payer: Aetna Managed Medicare |
$168.60
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$391.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$301.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$289.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$319.14
|
| Rate for Payer: Cash Price |
$173.70
|
| Rate for Payer: Cigna Commercial |
$553.99
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$336.98
|
| Rate for Payer: Health EOS Commercial |
$535.92
|
| Rate for Payer: HFN Commercial |
$553.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$451.62
|
| Rate for Payer: Multiplan Commercial |
$481.73
|
| Rate for Payer: NAPHCARE Commercial |
$361.30
|
| Rate for Payer: Preferred Network Access Commercial |
$553.99
|
| Rate for Payer: Quartz Beloit One Network |
$295.06
|
| Rate for Payer: Quartz Commercial |
$391.40
|
| Rate for Payer: Quartz Medicare Advantage |
$361.30
|
| Rate for Payer: The Alliance Commercial |
$301.08
|
| Rate for Payer: WEA Trust Commercial |
$331.19
|
| Rate for Payer: WPS Commercial |
$446.00
|
|
|
IV Pumps
|
Facility
|
OP
|
$620.00
|
|
| Hospital Charge Code |
2983452
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$180.54 |
| Max. Negotiated Rate |
$593.22 |
| Rate for Payer: Aetna Commercial |
$580.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$554.53
|
| Rate for Payer: Aetna Managed Medicare |
$180.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$419.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$322.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$309.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$341.74
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$593.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$360.84
|
| Rate for Payer: Health EOS Commercial |
$573.87
|
| Rate for Payer: HFN Commercial |
$593.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$483.60
|
| Rate for Payer: Multiplan Commercial |
$515.84
|
| Rate for Payer: NAPHCARE Commercial |
$386.88
|
| Rate for Payer: Preferred Network Access Commercial |
$593.22
|
| Rate for Payer: Quartz Beloit One Network |
$315.95
|
| Rate for Payer: Quartz Commercial |
$419.12
|
| Rate for Payer: Quartz Medicare Advantage |
$386.88
|
| Rate for Payer: The Alliance Commercial |
$322.40
|
| Rate for Payer: WEA Trust Commercial |
$354.64
|
| Rate for Payer: WPS Commercial |
$477.59
|
|
|
IV Pumps
|
Facility
|
IP
|
$620.00
|
|
| Hospital Charge Code |
2983452
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$315.95 |
| Max. Negotiated Rate |
$593.22 |
| Rate for Payer: Aetna Commercial |
$580.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$554.53
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$341.74
|
| Rate for Payer: Cash Price |
$186.00
|
| Rate for Payer: Cigna Commercial |
$593.22
|
| Rate for Payer: Health EOS Commercial |
$573.87
|
| Rate for Payer: HFN Commercial |
$593.22
|
| Rate for Payer: Multiplan Commercial |
$515.84
|
| Rate for Payer: Preferred Network Access Commercial |
$593.22
|
| Rate for Payer: Quartz Beloit One Network |
$315.95
|
| Rate for Payer: Quartz Commercial |
$386.88
|
| Rate for Payer: WEA Trust Commercial |
$354.64
|
| Rate for Payer: WPS Commercial |
$477.59
|
|
|
IV securement device - Peripheral IV Equipment:
|
Facility
|
OP
|
$139.00
|
|
| Hospital Charge Code |
3092876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$40.48 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Aetna Managed Medicare |
$40.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$72.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$69.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$80.90
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$108.42
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: NAPHCARE Commercial |
$86.74
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$93.96
|
| Rate for Payer: Quartz Medicare Advantage |
$86.74
|
| Rate for Payer: The Alliance Commercial |
$72.28
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
IV securement device - Peripheral IV Equipment:
|
Facility
|
IP
|
$139.00
|
|
| Hospital Charge Code |
3092876
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$70.83 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$130.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$124.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$76.62
|
| Rate for Payer: Cash Price |
$41.70
|
| Rate for Payer: Cigna Commercial |
$133.00
|
| Rate for Payer: Health EOS Commercial |
$128.66
|
| Rate for Payer: HFN Commercial |
$133.00
|
| Rate for Payer: Multiplan Commercial |
$115.65
|
| Rate for Payer: Preferred Network Access Commercial |
$133.00
|
| Rate for Payer: Quartz Beloit One Network |
$70.83
|
| Rate for Payer: Quartz Commercial |
$86.74
|
| Rate for Payer: WEA Trust Commercial |
$79.51
|
| Rate for Payer: WPS Commercial |
$107.07
|
|
|
I.V. Start Kit
|
Facility
|
OP
|
$9.00
|
|
| Hospital Charge Code |
3040292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Aetna Managed Medicare |
$2.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5.24
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7.02
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: NAPHCARE Commercial |
$5.62
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$6.08
|
| Rate for Payer: Quartz Medicare Advantage |
$5.62
|
| Rate for Payer: The Alliance Commercial |
$4.68
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
I.V. Start Kit
|
Facility
|
IP
|
$9.00
|
|
| Hospital Charge Code |
3040292
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$8.61 |
| Rate for Payer: Aetna Commercial |
$8.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4.96
|
| Rate for Payer: Cash Price |
$2.70
|
| Rate for Payer: Cigna Commercial |
$8.61
|
| Rate for Payer: Health EOS Commercial |
$8.33
|
| Rate for Payer: HFN Commercial |
$8.61
|
| Rate for Payer: Multiplan Commercial |
$7.49
|
| Rate for Payer: Preferred Network Access Commercial |
$8.61
|
| Rate for Payer: Quartz Beloit One Network |
$4.59
|
| Rate for Payer: Quartz Commercial |
$5.62
|
| Rate for Payer: WEA Trust Commercial |
$5.15
|
| Rate for Payer: WPS Commercial |
$6.93
|
|
|
IV START KIT DYNDV1539B
|
Facility
|
IP
|
$81.00
|
|
| Hospital Charge Code |
2962923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$50.54
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
IV START KIT DYNDV1539B
|
Facility
|
OP
|
$81.00
|
|
| Hospital Charge Code |
2962923
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$23.59 |
| Max. Negotiated Rate |
$77.50 |
| Rate for Payer: Aetna Commercial |
$75.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$72.45
|
| Rate for Payer: Aetna Managed Medicare |
$23.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$54.76
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$42.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$40.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$44.65
|
| Rate for Payer: Cash Price |
$24.30
|
| Rate for Payer: Cigna Commercial |
$77.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.14
|
| Rate for Payer: Health EOS Commercial |
$74.97
|
| Rate for Payer: HFN Commercial |
$77.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.18
|
| Rate for Payer: Multiplan Commercial |
$67.39
|
| Rate for Payer: NAPHCARE Commercial |
$50.54
|
| Rate for Payer: Preferred Network Access Commercial |
$77.50
|
| Rate for Payer: Quartz Beloit One Network |
$41.28
|
| Rate for Payer: Quartz Commercial |
$54.76
|
| Rate for Payer: Quartz Medicare Advantage |
$50.54
|
| Rate for Payer: The Alliance Commercial |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$46.33
|
| Rate for Payer: WPS Commercial |
$62.39
|
|
|
IVUS - AAA
|
Facility
|
IP
|
$3,825.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
2550986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,949.22 |
| Max. Negotiated Rate |
$3,659.76 |
| Rate for Payer: Aetna Commercial |
$3,580.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,421.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,108.34
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cigna Commercial |
$3,659.76
|
| Rate for Payer: Health EOS Commercial |
$3,540.42
|
| Rate for Payer: HFN Commercial |
$3,659.76
|
| Rate for Payer: Multiplan Commercial |
$3,182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,659.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,949.22
|
| Rate for Payer: Quartz Commercial |
$2,386.80
|
| Rate for Payer: WEA Trust Commercial |
$2,187.90
|
| Rate for Payer: WPS Commercial |
$2,946.40
|
|
|
IVUS - AAA
|
Professional
|
Both
|
$3,825.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
2550986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,750.32 |
| Max. Negotiated Rate |
$3,779.10 |
| Rate for Payer: Aetna Commercial |
$3,779.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,421.08
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cigna Commercial |
$3,779.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,989.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,386.80
|
| Rate for Payer: Health EOS Commercial |
$3,619.98
|
| Rate for Payer: HFN Commercial |
$3,779.10
|
| Rate for Payer: Multiplan Commercial |
$3,182.40
|
| Rate for Payer: Preferred Network Access Commercial |
$3,779.10
|
| Rate for Payer: Quartz Beloit One Network |
$1,750.32
|
| Rate for Payer: Quartz Commercial |
$2,267.46
|
| Rate for Payer: The Alliance Commercial |
$1,989.00
|
| Rate for Payer: WEA Trust Commercial |
$2,187.90
|
| Rate for Payer: WPS Commercial |
$2,946.40
|
|
|
IVUS - AAA
|
Facility
|
OP
|
$3,825.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
2550986
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,113.84 |
| Max. Negotiated Rate |
$3,659.76 |
| Rate for Payer: Aetna Commercial |
$3,580.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,421.08
|
| Rate for Payer: Aetna Managed Medicare |
$1,113.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,585.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,989.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,909.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,108.34
|
| Rate for Payer: Cash Price |
$1,147.50
|
| Rate for Payer: Cigna Commercial |
$3,659.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,226.15
|
| Rate for Payer: Health EOS Commercial |
$3,540.42
|
| Rate for Payer: HFN Commercial |
$3,659.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,983.50
|
| Rate for Payer: Multiplan Commercial |
$3,182.40
|
| Rate for Payer: NAPHCARE Commercial |
$2,386.80
|
| Rate for Payer: Preferred Network Access Commercial |
$3,659.76
|
| Rate for Payer: Quartz Beloit One Network |
$1,949.22
|
| Rate for Payer: Quartz Commercial |
$2,585.70
|
| Rate for Payer: Quartz Medicare Advantage |
$2,386.80
|
| Rate for Payer: The Alliance Commercial |
$1,989.00
|
| Rate for Payer: WEA Trust Commercial |
$2,187.90
|
| Rate for Payer: WPS Commercial |
$2,946.40
|
|
|
IV US Catheter AAA
|
Facility
|
IP
|
$8,232.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
4139308
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$4,195.03 |
| Max. Negotiated Rate |
$7,876.38 |
| Rate for Payer: Aetna Commercial |
$7,705.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,362.70
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,537.48
|
| Rate for Payer: Cash Price |
$2,469.60
|
| Rate for Payer: Cigna Commercial |
$7,876.38
|
| Rate for Payer: Health EOS Commercial |
$7,619.54
|
| Rate for Payer: HFN Commercial |
$7,876.38
|
| Rate for Payer: Multiplan Commercial |
$6,849.02
|
| Rate for Payer: Preferred Network Access Commercial |
$7,876.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,195.03
|
| Rate for Payer: Quartz Commercial |
$5,136.77
|
| Rate for Payer: WEA Trust Commercial |
$4,708.70
|
| Rate for Payer: WPS Commercial |
$6,341.11
|
|
|
IV US Catheter AAA
|
Facility
|
OP
|
$8,232.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
4139308
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$2,397.16 |
| Max. Negotiated Rate |
$7,876.38 |
| Rate for Payer: Aetna Commercial |
$7,705.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$7,362.70
|
| Rate for Payer: Aetna Managed Medicare |
$2,397.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$5,564.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$4,280.64
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,109.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$4,537.48
|
| Rate for Payer: Cash Price |
$2,469.60
|
| Rate for Payer: Cigna Commercial |
$7,876.38
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$4,791.02
|
| Rate for Payer: Health EOS Commercial |
$7,619.54
|
| Rate for Payer: HFN Commercial |
$7,876.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,420.96
|
| Rate for Payer: Multiplan Commercial |
$6,849.02
|
| Rate for Payer: NAPHCARE Commercial |
$5,136.77
|
| Rate for Payer: Preferred Network Access Commercial |
$7,876.38
|
| Rate for Payer: Quartz Beloit One Network |
$4,195.03
|
| Rate for Payer: Quartz Commercial |
$5,564.83
|
| Rate for Payer: Quartz Medicare Advantage |
$5,136.77
|
| Rate for Payer: The Alliance Commercial |
$4,280.64
|
| Rate for Payer: WEA Trust Commercial |
$4,708.70
|
| Rate for Payer: WPS Commercial |
$6,341.11
|
|
|
IV US Catheter Coronary
|
Facility
|
IP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
4139309
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$3,496.37 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,281.26
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
IV US Catheter Coronary
|
Facility
|
OP
|
$6,861.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
4139309
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,997.92 |
| Max. Negotiated Rate |
$6,564.60 |
| Rate for Payer: Aetna Commercial |
$6,421.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$6,136.48
|
| Rate for Payer: Aetna Managed Medicare |
$1,997.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$4,638.04
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,567.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,425.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$3,781.78
|
| Rate for Payer: Cash Price |
$2,058.30
|
| Rate for Payer: Cigna Commercial |
$6,564.60
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,993.10
|
| Rate for Payer: Health EOS Commercial |
$6,350.54
|
| Rate for Payer: HFN Commercial |
$6,564.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$5,351.58
|
| Rate for Payer: Multiplan Commercial |
$5,708.35
|
| Rate for Payer: NAPHCARE Commercial |
$4,281.26
|
| Rate for Payer: Preferred Network Access Commercial |
$6,564.60
|
| Rate for Payer: Quartz Beloit One Network |
$3,496.37
|
| Rate for Payer: Quartz Commercial |
$4,638.04
|
| Rate for Payer: Quartz Medicare Advantage |
$4,281.26
|
| Rate for Payer: The Alliance Commercial |
$3,567.72
|
| Rate for Payer: WEA Trust Commercial |
$3,924.49
|
| Rate for Payer: WPS Commercial |
$5,285.03
|
|
|
IVUS Coranary/BPG Ea Add Vessel +
|
Facility
|
OP
|
$1,747.00
|
|
|
Service Code
|
CPT 92979
|
| Hospital Charge Code |
3052472
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$508.73 |
| Max. Negotiated Rate |
$1,671.53 |
| Rate for Payer: Aetna Commercial |
$1,635.19
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,562.52
|
| Rate for Payer: Aetna Managed Medicare |
$508.73
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,180.97
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$908.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$872.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$962.95
|
| Rate for Payer: Cash Price |
$524.10
|
| Rate for Payer: Cigna Commercial |
$1,671.53
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,016.75
|
| Rate for Payer: Health EOS Commercial |
$1,617.02
|
| Rate for Payer: HFN Commercial |
$1,671.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,362.66
|
| Rate for Payer: Multiplan Commercial |
$1,453.50
|
| Rate for Payer: NAPHCARE Commercial |
$1,090.13
|
| Rate for Payer: Preferred Network Access Commercial |
$1,671.53
|
| Rate for Payer: Quartz Beloit One Network |
$890.27
|
| Rate for Payer: Quartz Commercial |
$1,180.97
|
| Rate for Payer: Quartz Medicare Advantage |
$1,090.13
|
| Rate for Payer: The Alliance Commercial |
$908.44
|
| Rate for Payer: United Healthcare PPO |
$1,362.66
|
| Rate for Payer: WEA Trust Commercial |
$999.28
|
| Rate for Payer: WPS Commercial |
$1,345.71
|
|
