|
Medicare Administration G0008
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
5470737
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$187.80 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.32
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$6.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$5.76
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.36
|
| 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 |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.04
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$6.72
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$10.68
|
| Rate for Payer: HFN Commercial |
$11.04
|
| 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 |
$9.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$11.04
|
| Rate for Payer: Quartz Beloit One Network |
$5.88
|
| Rate for Payer: Quartz Commercial |
$7.80
|
| 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 |
$9.00
|
| Rate for Payer: WEA Trust Commercial |
$6.60
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$8.89
|
|
|
Medicare G0008 - Admin Flu Virus
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
4308682
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.64 |
| Max. Negotiated Rate |
$187.80 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.64
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| 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 |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.07
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| 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 |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$11.70
|
| 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 |
$13.50
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Medicare G0008 - Admin Flu Virus
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
4308682
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.56 |
| Rate for Payer: Aetna Commercial |
$16.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.54
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$16.56
|
| Rate for Payer: Health EOS Commercial |
$16.02
|
| Rate for Payer: HFN Commercial |
$16.56
|
| Rate for Payer: Multiplan Commercial |
$14.40
|
| Rate for Payer: NAPHCARE Commercial |
$10.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16.56
|
| Rate for Payer: Quartz Beloit One Network |
$8.82
|
| Rate for Payer: Quartz Commercial |
$10.80
|
| Rate for Payer: WEA Trust Commercial |
$9.90
|
| Rate for Payer: WPS Commercial |
$13.33
|
|
|
Medicare G0009 - Medicare Pneumo. Admin Charge
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
4464874
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$32.16 |
| Max. Negotiated Rate |
$187.80 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.16
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| 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 |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| 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 |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$43.55
|
| 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 |
$50.25
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicare G0009 - Medicare Pneumo. Admin Charge
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
4464874
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicare G0009 - Medicare Pneumo. Admin Charge
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
4464874
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.26
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicare G0009 - Pnuemococcal 23, 2 years+
|
Professional
|
Both
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3013444
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$23.76 |
| Max. Negotiated Rate |
$57.26 |
| Rate for Payer: Aetna Commercial |
$51.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$27.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$32.40
|
| Rate for Payer: Health EOS Commercial |
$49.14
|
| Rate for Payer: HFN Commercial |
$51.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.26
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: Preferred Network Access Commercial |
$51.30
|
| Rate for Payer: Quartz Beloit One Network |
$23.76
|
| Rate for Payer: Quartz Commercial |
$30.78
|
| Rate for Payer: The Alliance Commercial |
$27.00
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Medicare G0009 - Pnuemococcal 23, 2 years+
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3013444
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$49.68 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| Rate for Payer: Multiplan Commercial |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$32.40
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$32.40
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Medicare G0009 - Pnuemococcal 23, 2 years+
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS G0009
|
| Hospital Charge Code |
3013444
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$25.92 |
| Max. Negotiated Rate |
$187.80 |
| Rate for Payer: Aetna Commercial |
$48.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$46.44
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.92
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.62
|
| 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 |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$49.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.22
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$48.06
|
| Rate for Payer: HFN Commercial |
$49.68
|
| 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 |
$43.20
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$49.68
|
| Rate for Payer: Quartz Beloit One Network |
$26.46
|
| Rate for Payer: Quartz Commercial |
$35.10
|
| 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 |
$40.50
|
| Rate for Payer: WEA Trust Commercial |
$29.70
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$40.00
|
|
|
Medicare G0010 - Admin Hep B Charge
|
Professional
|
Both
|
$67.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3013438
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$63.65 |
| Rate for Payer: Aetna Commercial |
$63.65
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$63.65
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$33.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.20
|
| Rate for Payer: Health EOS Commercial |
$60.97
|
| Rate for Payer: HFN Commercial |
$63.65
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.26
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$57.26
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: Preferred Network Access Commercial |
$63.65
|
| Rate for Payer: Quartz Beloit One Network |
$29.48
|
| Rate for Payer: Quartz Commercial |
$38.19
|
| Rate for Payer: The Alliance Commercial |
$33.50
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicare G0010 - Admin Hep B Charge
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3013438
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$32.83 |
| Max. Negotiated Rate |
$61.64 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| Rate for Payer: Multiplan Commercial |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$40.20
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$40.20
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicare G0010 - Admin Hep B Charge
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
HCPCS G0010
|
| Hospital Charge Code |
3013438
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$32.16 |
| Max. Negotiated Rate |
$187.80 |
| Rate for Payer: Aetna Commercial |
$60.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$57.62
|
| Rate for Payer: Aetna Managed Medicare |
$46.95
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$43.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$33.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$32.16
|
| Rate for Payer: Anthem Medicare Advantage |
$46.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$35.51
|
| 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 |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$61.64
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$46.95
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$46.95
|
| Rate for Payer: Health EOS Commercial |
$59.63
|
| Rate for Payer: HFN Commercial |
$61.64
|
| 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 |
$53.60
|
| Rate for Payer: NAPHCARE Commercial |
$70.42
|
| Rate for Payer: Preferred Network Access Commercial |
$61.64
|
| Rate for Payer: Quartz Beloit One Network |
$32.83
|
| Rate for Payer: Quartz Commercial |
$43.55
|
| 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 |
$50.25
|
| Rate for Payer: WEA Trust Commercial |
$36.85
|
| Rate for Payer: Wellcare Medicare |
$46.95
|
| Rate for Payer: WPS Commercial |
$49.63
|
|
|
Medicated packing strips charge
|
Facility
|
IP
|
$92.00
|
|
| Hospital Charge Code |
2958794
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Medicated packing strips charge
|
Facility
|
OP
|
$92.00
|
|
| Hospital Charge Code |
2958794
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$25.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$55.20
|
| Rate for Payer: The Alliance Commercial |
$368.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
Med Infusion Syringe Pump Tube
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
3101780
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$48.02 |
| Max. Negotiated Rate |
$90.16 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$58.80
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
Med Infusion Syringe Pump Tube
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
3101780
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$27.44 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna Commercial |
$88.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$84.28
|
| Rate for Payer: Aetna Managed Medicare |
$27.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$49.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$47.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$51.94
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$90.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$54.84
|
| Rate for Payer: Health EOS Commercial |
$87.22
|
| Rate for Payer: HFN Commercial |
$90.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$73.50
|
| Rate for Payer: Multiplan Commercial |
$78.40
|
| Rate for Payer: NAPHCARE Commercial |
$58.80
|
| Rate for Payer: Preferred Network Access Commercial |
$90.16
|
| Rate for Payer: Quartz Beloit One Network |
$48.02
|
| Rate for Payer: Quartz Commercial |
$63.70
|
| Rate for Payer: Quartz Medicare Advantage |
$58.80
|
| Rate for Payer: The Alliance Commercial |
$392.00
|
| Rate for Payer: WEA Trust Commercial |
$53.90
|
| Rate for Payer: WPS Commercial |
$72.59
|
|
|
MEDIPORE 2 TAPE
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2963518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$30.87 |
| Max. Negotiated Rate |
$57.96 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$37.80
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
MEDIPORE 2 TAPE
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2963518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$17.64 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna Commercial |
$56.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$54.18
|
| Rate for Payer: Aetna Managed Medicare |
$17.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$33.39
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$57.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$35.25
|
| Rate for Payer: Health EOS Commercial |
$56.07
|
| Rate for Payer: HFN Commercial |
$57.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$47.25
|
| Rate for Payer: Multiplan Commercial |
$50.40
|
| Rate for Payer: NAPHCARE Commercial |
$37.80
|
| Rate for Payer: Preferred Network Access Commercial |
$57.96
|
| Rate for Payer: Quartz Beloit One Network |
$30.87
|
| Rate for Payer: Quartz Commercial |
$40.95
|
| Rate for Payer: Quartz Medicare Advantage |
$37.80
|
| Rate for Payer: The Alliance Commercial |
$252.00
|
| Rate for Payer: WEA Trust Commercial |
$34.65
|
| Rate for Payer: WPS Commercial |
$46.66
|
|
|
Medium black foam
|
Facility
|
IP
|
$809.00
|
|
| Hospital Charge Code |
3006897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$396.41 |
| Max. Negotiated Rate |
$744.28 |
| Rate for Payer: Aetna Commercial |
$728.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.77
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$744.28
|
| Rate for Payer: Health EOS Commercial |
$720.01
|
| Rate for Payer: HFN Commercial |
$744.28
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: NAPHCARE Commercial |
$485.40
|
| Rate for Payer: Preferred Network Access Commercial |
$744.28
|
| Rate for Payer: Quartz Beloit One Network |
$396.41
|
| Rate for Payer: Quartz Commercial |
$485.40
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
|
Medium black foam
|
Facility
|
OP
|
$809.00
|
|
| Hospital Charge Code |
3006897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$226.52 |
| Max. Negotiated Rate |
$3,236.00 |
| Rate for Payer: Aetna Commercial |
$728.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$695.74
|
| Rate for Payer: Aetna Managed Medicare |
$226.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$525.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$404.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$388.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$428.77
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$744.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$452.72
|
| Rate for Payer: Health EOS Commercial |
$720.01
|
| Rate for Payer: HFN Commercial |
$744.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$606.75
|
| Rate for Payer: Multiplan Commercial |
$647.20
|
| Rate for Payer: NAPHCARE Commercial |
$485.40
|
| Rate for Payer: Preferred Network Access Commercial |
$744.28
|
| Rate for Payer: Quartz Beloit One Network |
$396.41
|
| Rate for Payer: Quartz Commercial |
$525.85
|
| Rate for Payer: Quartz Medicare Advantage |
$485.40
|
| Rate for Payer: The Alliance Commercial |
$3,236.00
|
| Rate for Payer: WEA Trust Commercial |
$444.95
|
| Rate for Payer: WPS Commercial |
$599.23
|
|
|
Medium joint or bursa w/ultrasound guidance 20606
|
Professional
|
Both
|
$1,708.00
|
|
|
Service Code
|
CPT 20606
|
| Hospital Charge Code |
4500692
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.23 |
| Max. Negotiated Rate |
$1,622.60 |
| Rate for Payer: Aetna Commercial |
$1,622.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.88
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cash Price |
$512.40
|
| Rate for Payer: Cigna Commercial |
$1,622.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$61.23
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,024.80
|
| Rate for Payer: Health EOS Commercial |
$1,554.28
|
| Rate for Payer: HFN Commercial |
$1,622.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$176.64
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$176.64
|
| Rate for Payer: Multiplan Commercial |
$1,366.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,622.60
|
| Rate for Payer: Quartz Beloit One Network |
$751.52
|
| Rate for Payer: Quartz Commercial |
$973.56
|
| Rate for Payer: The Alliance Commercial |
$854.00
|
| Rate for Payer: United Healthcare Medicaid |
$61.23
|
| Rate for Payer: WEA Trust Commercial |
$939.40
|
| Rate for Payer: WPS Commercial |
$1,265.12
|
|
|
Medroxyprogesterone 150 mg Charge
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
2983537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$305.90 |
| Rate for Payer: Aetna Commercial |
$305.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$305.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.57
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.20
|
| Rate for Payer: Health EOS Commercial |
$293.02
|
| Rate for Payer: HFN Commercial |
$305.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: Preferred Network Access Commercial |
$305.90
|
| Rate for Payer: Quartz Beloit One Network |
$141.68
|
| Rate for Payer: Quartz Commercial |
$183.54
|
| Rate for Payer: The Alliance Commercial |
$161.00
|
| Rate for Payer: United Healthcare Medicaid |
$0.57
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
Medroxyprogesterone 150 mg Charge
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
2983537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$90.16 |
| Max. Negotiated Rate |
$1,288.00 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Aetna Managed Medicare |
$90.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$209.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$161.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$154.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$180.19
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$241.50
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$209.30
|
| Rate for Payer: Quartz Medicare Advantage |
$193.20
|
| Rate for Payer: The Alliance Commercial |
$1,288.00
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
Medroxyprogesterone 150 mg Charge
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
2983537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$157.78 |
| Max. Negotiated Rate |
$296.24 |
| Rate for Payer: Aetna Commercial |
$289.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$276.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$170.66
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$296.24
|
| Rate for Payer: Health EOS Commercial |
$286.58
|
| Rate for Payer: HFN Commercial |
$296.24
|
| Rate for Payer: Multiplan Commercial |
$257.60
|
| Rate for Payer: NAPHCARE Commercial |
$193.20
|
| Rate for Payer: Preferred Network Access Commercial |
$296.24
|
| Rate for Payer: Quartz Beloit One Network |
$157.78
|
| Rate for Payer: Quartz Commercial |
$193.20
|
| Rate for Payer: WEA Trust Commercial |
$177.10
|
| Rate for Payer: WPS Commercial |
$238.51
|
|
|
MENDER MENISCUS II 7209485
|
Facility
|
IP
|
$1,824.00
|
|
| Hospital Charge Code |
2965964
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$893.76 |
| Max. Negotiated Rate |
$1,678.08 |
| Rate for Payer: Aetna Commercial |
$1,641.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,568.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$966.72
|
| Rate for Payer: Cash Price |
$547.20
|
| Rate for Payer: Cigna Commercial |
$1,678.08
|
| Rate for Payer: Health EOS Commercial |
$1,623.36
|
| Rate for Payer: HFN Commercial |
$1,678.08
|
| Rate for Payer: Multiplan Commercial |
$1,459.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,094.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,678.08
|
| Rate for Payer: Quartz Beloit One Network |
$893.76
|
| Rate for Payer: Quartz Commercial |
$1,094.40
|
| Rate for Payer: WEA Trust Commercial |
$1,003.20
|
| Rate for Payer: WPS Commercial |
$1,351.04
|
|
