|
Medicare Administration G0008
|
Professional
|
Both
|
$12.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
5470737
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$59.55 |
| Rate for Payer: Aetna Commercial |
$11.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$6.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$7.49
|
| Rate for Payer: Health EOS Commercial |
$11.36
|
| Rate for Payer: HFN Commercial |
$11.86
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11.86
|
| Rate for Payer: Quartz Beloit One Network |
$5.49
|
| Rate for Payer: Quartz Commercial |
$7.11
|
| Rate for Payer: The Alliance Commercial |
$6.24
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
Medicare Administration G0008
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
5470737
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna Commercial |
$11.23
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$10.73
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$6.61
|
| Rate for Payer: Cash Price |
$3.60
|
| Rate for Payer: Cigna Commercial |
$11.48
|
| Rate for Payer: Health EOS Commercial |
$11.11
|
| Rate for Payer: HFN Commercial |
$11.48
|
| Rate for Payer: Multiplan Commercial |
$9.98
|
| Rate for Payer: Preferred Network Access Commercial |
$11.48
|
| Rate for Payer: Quartz Beloit One Network |
$6.12
|
| Rate for Payer: Quartz Commercial |
$7.49
|
| Rate for Payer: WEA Trust Commercial |
$6.86
|
| Rate for Payer: WPS Commercial |
$9.24
|
|
|
Medicare G0008 - Admin Flu Virus
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
4308682
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$17.22 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| Rate for Payer: Multiplan Commercial |
$14.98
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.23
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
Medicare G0008 - Admin Flu Virus
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS G0008
|
| Hospital Charge Code |
4308682
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16.10
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$12.17
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8.99
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9.92
|
| 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 |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna Commercial |
$17.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$16.66
|
| Rate for Payer: HFN Commercial |
$17.22
|
| 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 |
$14.98
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$17.22
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$12.17
|
| 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 |
$14.04
|
| Rate for Payer: WEA Trust Commercial |
$10.30
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$13.87
|
|
|
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 |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
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 |
$30.66 |
| Max. Negotiated Rate |
$66.20 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.81
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
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 |
$33.45 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| 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 |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| 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 |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| 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 |
$52.26
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
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 |
$24.71 |
| Max. Negotiated Rate |
$59.55 |
| Rate for Payer: Aetna Commercial |
$53.35
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$53.35
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$28.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33.70
|
| Rate for Payer: Health EOS Commercial |
$51.11
|
| Rate for Payer: HFN Commercial |
$53.35
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$53.35
|
| Rate for Payer: Quartz Beloit One Network |
$24.71
|
| Rate for Payer: Quartz Commercial |
$32.01
|
| Rate for Payer: The Alliance Commercial |
$28.08
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
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 |
$27.52 |
| Max. Negotiated Rate |
$51.67 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| Rate for Payer: Multiplan Commercial |
$44.93
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$33.70
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
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 |
$26.96 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$50.54
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$48.30
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$36.50
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.96
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.76
|
| 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 |
$16.20
|
| Rate for Payer: Cash Price |
$16.20
|
| Rate for Payer: Cigna Commercial |
$51.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31.43
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$49.98
|
| Rate for Payer: HFN Commercial |
$51.67
|
| 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 |
$44.93
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$51.67
|
| Rate for Payer: Quartz Beloit One Network |
$27.52
|
| Rate for Payer: Quartz Commercial |
$36.50
|
| 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 |
$42.12
|
| Rate for Payer: WEA Trust Commercial |
$30.89
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$41.60
|
|
|
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 |
$33.45 |
| Max. Negotiated Rate |
$197.10 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Aetna Managed Medicare |
$49.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.29
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$34.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.45
|
| Rate for Payer: Anthem Medicare Advantage |
$49.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| 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 |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$49.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$38.99
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$49.28
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| 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 |
$55.74
|
| Rate for Payer: NAPHCARE Commercial |
$73.91
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$45.29
|
| 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 |
$52.26
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: Wellcare Medicare |
$49.28
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
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 |
$30.66 |
| Max. Negotiated Rate |
$66.20 |
| Rate for Payer: Aetna Commercial |
$66.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$66.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.81
|
| Rate for Payer: Health EOS Commercial |
$63.41
|
| Rate for Payer: HFN Commercial |
$66.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.55
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$66.20
|
| Rate for Payer: Quartz Beloit One Network |
$30.66
|
| Rate for Payer: Quartz Commercial |
$39.72
|
| Rate for Payer: The Alliance Commercial |
$34.84
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
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 |
$34.14 |
| Max. Negotiated Rate |
$64.11 |
| Rate for Payer: Aetna Commercial |
$62.71
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$59.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$36.93
|
| Rate for Payer: Cash Price |
$20.10
|
| Rate for Payer: Cigna Commercial |
$64.11
|
| Rate for Payer: Health EOS Commercial |
$62.02
|
| Rate for Payer: HFN Commercial |
$64.11
|
| Rate for Payer: Multiplan Commercial |
$55.74
|
| Rate for Payer: Preferred Network Access Commercial |
$64.11
|
| Rate for Payer: Quartz Beloit One Network |
$34.14
|
| Rate for Payer: Quartz Commercial |
$41.81
|
| Rate for Payer: WEA Trust Commercial |
$38.32
|
| Rate for Payer: WPS Commercial |
$51.61
|
|
|
Medicated packing strips charge
|
Facility
|
OP
|
$92.00
|
|
| Hospital Charge Code |
2958794
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$26.79 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Aetna Managed Medicare |
$26.79
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$62.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$47.84
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$45.93
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$53.54
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.76
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: NAPHCARE Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$62.19
|
| Rate for Payer: Quartz Medicare Advantage |
$57.41
|
| Rate for Payer: The Alliance Commercial |
$47.84
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
Medicated packing strips charge
|
Facility
|
IP
|
$92.00
|
|
| Hospital Charge Code |
2958794
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$88.03 |
| Rate for Payer: Aetna Commercial |
$86.11
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$82.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$50.71
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$88.03
|
| Rate for Payer: Health EOS Commercial |
$85.16
|
| Rate for Payer: HFN Commercial |
$88.03
|
| Rate for Payer: Multiplan Commercial |
$76.54
|
| Rate for Payer: Preferred Network Access Commercial |
$88.03
|
| Rate for Payer: Quartz Beloit One Network |
$46.88
|
| Rate for Payer: Quartz Commercial |
$57.41
|
| Rate for Payer: WEA Trust Commercial |
$52.62
|
| Rate for Payer: WPS Commercial |
$70.87
|
|
|
MEDICATION ADMINISTRATION & OBSERVATION
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
EAPG 00322
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Anthem Medicaid |
$15.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$15.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.12
|
| Rate for Payer: Dean Health Medicaid |
$15.12
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.12
|
| Rate for Payer: Managed Health Services Medicaid |
$15.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.12
|
| Rate for Payer: United Healthcare Medicaid |
$15.12
|
|
|
Med Infusion Syringe Pump Tube
|
Facility
|
IP
|
$98.00
|
|
| Hospital Charge Code |
3101780
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$61.15
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
Med Infusion Syringe Pump Tube
|
Facility
|
OP
|
$98.00
|
|
| Hospital Charge Code |
3101780
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$28.54 |
| Max. Negotiated Rate |
$93.77 |
| Rate for Payer: Aetna Commercial |
$91.73
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$87.65
|
| Rate for Payer: Aetna Managed Medicare |
$28.54
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$66.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$54.02
|
| Rate for Payer: Cash Price |
$29.40
|
| Rate for Payer: Cigna Commercial |
$93.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$90.71
|
| Rate for Payer: HFN Commercial |
$93.77
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$76.44
|
| Rate for Payer: Multiplan Commercial |
$81.54
|
| Rate for Payer: NAPHCARE Commercial |
$61.15
|
| Rate for Payer: Preferred Network Access Commercial |
$93.77
|
| Rate for Payer: Quartz Beloit One Network |
$49.94
|
| Rate for Payer: Quartz Commercial |
$66.25
|
| Rate for Payer: Quartz Medicare Advantage |
$61.15
|
| Rate for Payer: The Alliance Commercial |
$50.96
|
| Rate for Payer: WEA Trust Commercial |
$56.06
|
| Rate for Payer: WPS Commercial |
$75.49
|
|
|
MEDIPORE 2 TAPE
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
2963518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$18.35 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Aetna Managed Medicare |
$18.35
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42.59
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.67
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$49.14
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: NAPHCARE Commercial |
$39.31
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$42.59
|
| Rate for Payer: Quartz Medicare Advantage |
$39.31
|
| Rate for Payer: The Alliance Commercial |
$32.76
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
MEDIPORE 2 TAPE
|
Facility
|
IP
|
$63.00
|
|
| Hospital Charge Code |
2963518
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$60.28 |
| Rate for Payer: Aetna Commercial |
$58.97
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$56.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$34.73
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna Commercial |
$60.28
|
| Rate for Payer: Health EOS Commercial |
$58.31
|
| Rate for Payer: HFN Commercial |
$60.28
|
| Rate for Payer: Multiplan Commercial |
$52.42
|
| Rate for Payer: Preferred Network Access Commercial |
$60.28
|
| Rate for Payer: Quartz Beloit One Network |
$32.10
|
| Rate for Payer: Quartz Commercial |
$39.31
|
| Rate for Payer: WEA Trust Commercial |
$36.04
|
| Rate for Payer: WPS Commercial |
$48.53
|
|
|
Medium black foam
|
Facility
|
IP
|
$809.00
|
|
| Hospital Charge Code |
3006897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$412.27 |
| Max. Negotiated Rate |
$774.05 |
| Rate for Payer: Aetna Commercial |
$757.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$723.57
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$445.92
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$774.05
|
| Rate for Payer: Health EOS Commercial |
$748.81
|
| Rate for Payer: HFN Commercial |
$774.05
|
| Rate for Payer: Multiplan Commercial |
$673.09
|
| Rate for Payer: Preferred Network Access Commercial |
$774.05
|
| Rate for Payer: Quartz Beloit One Network |
$412.27
|
| Rate for Payer: Quartz Commercial |
$504.82
|
| Rate for Payer: WEA Trust Commercial |
$462.75
|
| Rate for Payer: WPS Commercial |
$623.17
|
|
|
Medium black foam
|
Facility
|
OP
|
$809.00
|
|
| Hospital Charge Code |
3006897
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$235.58 |
| Max. Negotiated Rate |
$774.05 |
| Rate for Payer: Aetna Commercial |
$757.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$723.57
|
| Rate for Payer: Aetna Managed Medicare |
$235.58
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$546.88
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$420.68
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$403.85
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$445.92
|
| Rate for Payer: Cash Price |
$242.70
|
| Rate for Payer: Cigna Commercial |
$774.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$470.84
|
| Rate for Payer: Health EOS Commercial |
$748.81
|
| Rate for Payer: HFN Commercial |
$774.05
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$631.02
|
| Rate for Payer: Multiplan Commercial |
$673.09
|
| Rate for Payer: NAPHCARE Commercial |
$504.82
|
| Rate for Payer: Preferred Network Access Commercial |
$774.05
|
| Rate for Payer: Quartz Beloit One Network |
$412.27
|
| Rate for Payer: Quartz Commercial |
$546.88
|
| Rate for Payer: Quartz Medicare Advantage |
$504.82
|
| Rate for Payer: The Alliance Commercial |
$420.68
|
| Rate for Payer: WEA Trust Commercial |
$462.75
|
| Rate for Payer: WPS Commercial |
$623.17
|
|
|
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 |
$43.32 |
| Max. Negotiated Rate |
$1,687.50 |
| Rate for Payer: Aetna Commercial |
$1,687.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,527.64
|
| Rate for Payer: Aetna Managed Medicare |
$43.32
|
| Rate for Payer: Anthem Medicare Advantage |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$43.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$43.32
|
| 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 |
$1,687.50
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$63.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$43.32
|
| Rate for Payer: Health EOS Commercial |
$1,616.45
|
| Rate for Payer: HFN Commercial |
$1,687.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$183.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$183.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$43.32
|
| Rate for Payer: Multiplan Commercial |
$1,421.06
|
| Rate for Payer: NAPHCARE Commercial |
$64.97
|
| Rate for Payer: Preferred Network Access Commercial |
$1,687.50
|
| Rate for Payer: Quartz Beloit One Network |
$781.58
|
| Rate for Payer: Quartz Commercial |
$1,012.50
|
| Rate for Payer: Quartz Medicare Advantage |
$43.32
|
| Rate for Payer: The Alliance Commercial |
$184.09
|
| Rate for Payer: United Healthcare Medicaid |
$63.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$43.32
|
| Rate for Payer: WEA Trust Commercial |
$976.98
|
| Rate for Payer: WPS Commercial |
$194.92
|
|
|
Medroxyprogesterone 150 mg Charge
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
2983537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$318.14 |
| Rate for Payer: Aetna Commercial |
$318.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$318.14
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$200.93
|
| Rate for Payer: Health EOS Commercial |
$304.74
|
| Rate for Payer: HFN Commercial |
$318.14
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: Preferred Network Access Commercial |
$318.14
|
| Rate for Payer: Quartz Beloit One Network |
$147.35
|
| Rate for Payer: Quartz Commercial |
$190.88
|
| Rate for Payer: The Alliance Commercial |
$167.44
|
| Rate for Payer: United Healthcare Medicaid |
$0.59
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$248.04
|
|
|
Medroxyprogesterone 150 mg Charge
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS J1050
|
| Hospital Charge Code |
2983537
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.77 |
| Max. Negotiated Rate |
$308.09 |
| Rate for Payer: Aetna Commercial |
$301.39
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$288.00
|
| Rate for Payer: Aetna Managed Medicare |
$93.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$217.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$167.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$160.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$177.49
|
| Rate for Payer: Cash Price |
$96.60
|
| Rate for Payer: Cigna Commercial |
$308.09
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$187.40
|
| Rate for Payer: Health EOS Commercial |
$298.04
|
| Rate for Payer: HFN Commercial |
$308.09
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$251.16
|
| Rate for Payer: Multiplan Commercial |
$267.90
|
| Rate for Payer: NAPHCARE Commercial |
$200.93
|
| Rate for Payer: Preferred Network Access Commercial |
$308.09
|
| Rate for Payer: Quartz Beloit One Network |
$164.09
|
| Rate for Payer: Quartz Commercial |
$217.67
|
| Rate for Payer: Quartz Medicare Advantage |
$200.93
|
| Rate for Payer: The Alliance Commercial |
$167.44
|
| Rate for Payer: WEA Trust Commercial |
$184.18
|
| Rate for Payer: WPS Commercial |
$248.04
|
|
