|
Iodine 24 Hour Urine
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
1040832
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.78 |
| Max. Negotiated Rate |
$277.47 |
| Rate for Payer: Aetna Commercial |
$271.44
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$259.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$159.85
|
| Rate for Payer: Cash Price |
$87.00
|
| Rate for Payer: Cigna Commercial |
$277.47
|
| Rate for Payer: Health EOS Commercial |
$268.42
|
| Rate for Payer: HFN Commercial |
$277.47
|
| Rate for Payer: Multiplan Commercial |
$241.28
|
| Rate for Payer: Preferred Network Access Commercial |
$277.47
|
| Rate for Payer: Quartz Beloit One Network |
$147.78
|
| Rate for Payer: Quartz Commercial |
$180.96
|
| Rate for Payer: WEA Trust Commercial |
$165.88
|
| Rate for Payer: WPS Commercial |
$223.39
|
|
|
Iodine Level
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.60 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$71.76
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
Iodine Level
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$110.03 |
| Rate for Payer: Aetna Commercial |
$107.64
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$93.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.59
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$63.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$110.03
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$25.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.93
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$106.44
|
| Rate for Payer: HFN Commercial |
$110.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.20
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$25.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$25.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$110.03
|
| Rate for Payer: Quartz Beloit One Network |
$58.60
|
| Rate for Payer: Quartz Commercial |
$77.74
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$100.21
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: United Healthcare PPO |
$89.70
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: Wellcare Medicare |
$25.05
|
| Rate for Payer: WPS Commercial |
$88.58
|
|
|
Iodine Level
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
5426836
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$113.62 |
| Rate for Payer: Aetna Commercial |
$113.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$102.86
|
| Rate for Payer: Aetna Managed Medicare |
$25.05
|
| Rate for Payer: Anthem Medicare Advantage |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$25.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$25.05
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$113.62
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$59.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$25.05
|
| Rate for Payer: Health EOS Commercial |
$108.84
|
| Rate for Payer: HFN Commercial |
$113.62
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.44
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$88.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$25.05
|
| Rate for Payer: Multiplan Commercial |
$95.68
|
| Rate for Payer: NAPHCARE Commercial |
$37.58
|
| Rate for Payer: Preferred Network Access Commercial |
$113.62
|
| Rate for Payer: Quartz Beloit One Network |
$52.62
|
| Rate for Payer: Quartz Commercial |
$68.17
|
| Rate for Payer: Quartz Medicare Advantage |
$25.05
|
| Rate for Payer: The Alliance Commercial |
$98.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$25.05
|
| Rate for Payer: WEA Trust Commercial |
$65.78
|
| Rate for Payer: WPS Commercial |
$110.24
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
OP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Aetna Managed Medicare |
$26.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$60.84
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$52.38
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$70.20
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: NAPHCARE Commercial |
$56.16
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$60.84
|
| Rate for Payer: Quartz Medicare Advantage |
$56.16
|
| Rate for Payer: The Alliance Commercial |
$46.80
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
IODOSORB CADEXOMER GEL 10GM TUBE 6602-1240-14
|
Facility
|
IP
|
$90.00
|
|
| Hospital Charge Code |
2974069
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.86 |
| Max. Negotiated Rate |
$86.11 |
| Rate for Payer: Aetna Commercial |
$84.24
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$80.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$49.61
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna Commercial |
$86.11
|
| Rate for Payer: Health EOS Commercial |
$83.30
|
| Rate for Payer: HFN Commercial |
$86.11
|
| Rate for Payer: Multiplan Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$86.11
|
| Rate for Payer: Quartz Beloit One Network |
$45.86
|
| Rate for Payer: Quartz Commercial |
$56.16
|
| Rate for Payer: WEA Trust Commercial |
$51.48
|
| Rate for Payer: WPS Commercial |
$69.33
|
|
|
Ion 2.25mm x 12mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 12mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 12mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162862
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 16mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 16mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 16mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162864
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 20mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 20mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 20mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162866
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 24mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 24mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 24mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162868
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 28mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 28mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 28mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162870
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 32mm
|
Professional
|
Both
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,561.55 |
| Max. Negotiated Rate |
$20,644.26 |
| Rate for Payer: Aetna Commercial |
$20,644.26
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$20,644.26
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$10,865.40
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,038.48
|
| Rate for Payer: Health EOS Commercial |
$19,775.03
|
| Rate for Payer: HFN Commercial |
$20,644.26
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$20,644.26
|
| Rate for Payer: Quartz Beloit One Network |
$9,561.55
|
| Rate for Payer: Quartz Commercial |
$12,386.56
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 32mm
|
Facility
|
IP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,648.09 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$13,038.48
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 32mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162872
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
|
Ion 2.25mm x 8mm
|
Facility
|
OP
|
$20,895.00
|
|
|
Service Code
|
HCPCS C1784
|
| Hospital Charge Code |
1162860
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,084.62 |
| Max. Negotiated Rate |
$19,992.34 |
| Rate for Payer: Aetna Commercial |
$19,557.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$18,688.49
|
| Rate for Payer: Aetna Managed Medicare |
$6,084.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,125.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10,865.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,430.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11,517.32
|
| Rate for Payer: Cash Price |
$6,268.50
|
| Rate for Payer: Cigna Commercial |
$19,992.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,160.89
|
| Rate for Payer: Health EOS Commercial |
$19,340.41
|
| Rate for Payer: HFN Commercial |
$19,992.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,298.10
|
| Rate for Payer: Multiplan Commercial |
$17,384.64
|
| Rate for Payer: NAPHCARE Commercial |
$13,038.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19,992.34
|
| Rate for Payer: Quartz Beloit One Network |
$10,648.09
|
| Rate for Payer: Quartz Commercial |
$14,125.02
|
| Rate for Payer: Quartz Medicare Advantage |
$13,038.48
|
| Rate for Payer: The Alliance Commercial |
$10,865.40
|
| Rate for Payer: WEA Trust Commercial |
$11,951.94
|
| Rate for Payer: WPS Commercial |
$16,095.42
|
|
