|
MMRV Vaccine, SC 90710
|
Professional
|
Both
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$173.36 |
| Max. Negotiated Rate |
$408.08 |
| Rate for Payer: Aetna Commercial |
$374.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$374.30
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.40
|
| Rate for Payer: Health EOS Commercial |
$358.54
|
| Rate for Payer: HFN Commercial |
$374.30
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.08
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: Preferred Network Access Commercial |
$374.30
|
| Rate for Payer: Quartz Beloit One Network |
$173.36
|
| Rate for Payer: Quartz Commercial |
$224.58
|
| Rate for Payer: The Alliance Commercial |
$197.00
|
| Rate for Payer: United Healthcare Medicaid |
$195.05
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
MMRV Vaccine, SC 90710
|
Facility
|
OP
|
$394.00
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
3455570
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$137.65 |
| Max. Negotiated Rate |
$550.60 |
| Rate for Payer: Aetna Commercial |
$354.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$338.84
|
| Rate for Payer: Aetna Managed Medicare |
$137.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$256.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$197.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$189.12
|
| Rate for Payer: Anthem Medicare Advantage |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$208.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.65
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cash Price |
$118.20
|
| Rate for Payer: Cigna Commercial |
$362.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$220.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.65
|
| Rate for Payer: Health EOS Commercial |
$350.66
|
| Rate for Payer: HFN Commercial |
$362.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$512.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.65
|
| Rate for Payer: Multiplan Commercial |
$315.20
|
| Rate for Payer: NAPHCARE Commercial |
$206.48
|
| Rate for Payer: Preferred Network Access Commercial |
$362.48
|
| Rate for Payer: Quartz Beloit One Network |
$193.06
|
| Rate for Payer: Quartz Commercial |
$256.10
|
| Rate for Payer: Quartz Medicare Advantage |
$137.65
|
| Rate for Payer: The Alliance Commercial |
$550.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.65
|
| Rate for Payer: WEA Trust Commercial |
$216.70
|
| Rate for Payer: Wellcare Medicare |
$137.65
|
| Rate for Payer: WPS Commercial |
$291.84
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Facility
|
OP
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$550.60 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Aetna Managed Medicare |
$137.65
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$13.54
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$10.42
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10.00
|
| Rate for Payer: Anthem Medicare Advantage |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$137.65
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$137.65
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$137.65
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$11.66
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$137.65
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$512.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$137.65
|
| Rate for Payer: Independent Care Health Plan Medicare |
$137.65
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$137.65
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$137.65
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$206.48
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$13.54
|
| Rate for Payer: Quartz Medicare Advantage |
$137.65
|
| Rate for Payer: The Alliance Commercial |
$550.60
|
| Rate for Payer: United Healthcare Medicare Advantage |
$137.65
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: Wellcare Medicare |
$137.65
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Professional
|
Both
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.17 |
| Max. Negotiated Rate |
$408.08 |
| Rate for Payer: Aetna Commercial |
$19.79
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.79
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$195.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.50
|
| Rate for Payer: Health EOS Commercial |
$18.96
|
| Rate for Payer: HFN Commercial |
$19.79
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$408.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$408.08
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: Preferred Network Access Commercial |
$19.79
|
| Rate for Payer: Quartz Beloit One Network |
$9.17
|
| Rate for Payer: Quartz Commercial |
$11.87
|
| Rate for Payer: The Alliance Commercial |
$10.42
|
| Rate for Payer: United Healthcare Medicaid |
$195.05
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
MMRV Vaccine, SC 90710 VFC Charge
|
Facility
|
IP
|
$20.83
|
|
|
Service Code
|
CPT 90710
|
| Hospital Charge Code |
5084632
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.21 |
| Max. Negotiated Rate |
$19.16 |
| Rate for Payer: Aetna Commercial |
$18.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$17.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$11.04
|
| Rate for Payer: Cash Price |
$6.25
|
| Rate for Payer: Cigna Commercial |
$19.16
|
| Rate for Payer: Health EOS Commercial |
$18.54
|
| Rate for Payer: HFN Commercial |
$19.16
|
| Rate for Payer: Multiplan Commercial |
$16.66
|
| Rate for Payer: NAPHCARE Commercial |
$12.50
|
| Rate for Payer: Preferred Network Access Commercial |
$19.16
|
| Rate for Payer: Quartz Beloit One Network |
$10.21
|
| Rate for Payer: Quartz Commercial |
$12.50
|
| Rate for Payer: WEA Trust Commercial |
$11.46
|
| Rate for Payer: WPS Commercial |
$15.43
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$166.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$166.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.92
|
| Rate for Payer: Health EOS Commercial |
$159.25
|
| Rate for Payer: HFN Commercial |
$166.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: Preferred Network Access Commercial |
$166.25
|
| Rate for Payer: Quartz Beloit One Network |
$77.00
|
| Rate for Payer: Quartz Commercial |
$99.75
|
| Rate for Payer: The Alliance Commercial |
$87.50
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Aetna Managed Medicare |
$49.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.05
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$113.75
|
| Rate for Payer: Quartz Medicare Advantage |
$105.00
|
| Rate for Payer: The Alliance Commercial |
$700.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
Moderna 25mcg/0.25mL (6m-11yr) - Covid Vaccine
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 91321
|
| Hospital Charge Code |
6219808
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Aetna Managed Medicare |
$49.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$193.05
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$113.75
|
| Rate for Payer: Quartz Medicare Advantage |
$105.00
|
| Rate for Payer: The Alliance Commercial |
$700.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
Moderna 50mcg/0.5mL (12 yr & older) - Covid Vaccine
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
CPT 91322
|
| Hospital Charge Code |
6219809
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$166.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$166.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$145.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$145.92
|
| Rate for Payer: Health EOS Commercial |
$159.25
|
| Rate for Payer: HFN Commercial |
$166.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: Preferred Network Access Commercial |
$166.25
|
| Rate for Payer: Quartz Beloit One Network |
$77.00
|
| Rate for Payer: Quartz Commercial |
$99.75
|
| Rate for Payer: The Alliance Commercial |
$87.50
|
| Rate for Payer: United Healthcare Medicaid |
$145.92
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$364.80
|
|
|
Mod Sed Same Phys/QHP Each Addl 15 Mins 99153
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
5160609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.96 |
| Max. Negotiated Rate |
$328.00 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Aetna Managed Medicare |
$22.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$53.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$41.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$39.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$45.89
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.50
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$53.30
|
| Rate for Payer: Quartz Medicare Advantage |
$49.20
|
| Rate for Payer: The Alliance Commercial |
$328.00
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
Mod Sed Same Phys/QHP Each Addl 15 Mins 99153
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 99153
|
| Hospital Charge Code |
5160609
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$40.18 |
| Max. Negotiated Rate |
$75.44 |
| Rate for Payer: Aetna Commercial |
$73.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$70.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$43.46
|
| Rate for Payer: Cash Price |
$24.60
|
| Rate for Payer: Cigna Commercial |
$75.44
|
| Rate for Payer: Health EOS Commercial |
$72.98
|
| Rate for Payer: HFN Commercial |
$75.44
|
| Rate for Payer: Multiplan Commercial |
$65.60
|
| Rate for Payer: NAPHCARE Commercial |
$49.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.44
|
| Rate for Payer: Quartz Beloit One Network |
$40.18
|
| Rate for Payer: Quartz Commercial |
$49.20
|
| Rate for Payer: WEA Trust Commercial |
$45.10
|
| Rate for Payer: WPS Commercial |
$60.74
|
|
|
.MOG Antibody Titer, Serum
|
Facility
|
OP
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$631.12 |
| Rate for Payer: Aetna Commercial |
$617.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.96
|
| Rate for Payer: Aetna Managed Medicare |
$12.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.19
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.09
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.00
|
| Rate for Payer: Anthem Medicaid |
$12.05
|
| Rate for Payer: Anthem Medicare Advantage |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.05
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.05
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$631.12
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$12.05
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$383.89
|
| Rate for Payer: Dean Health Medicaid |
$12.05
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.05
|
| Rate for Payer: Health EOS Commercial |
$610.54
|
| Rate for Payer: HFN Commercial |
$631.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$44.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$12.05
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.05
|
| Rate for Payer: Managed Health Services Medicaid |
$12.53
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.05
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.05
|
| Rate for Payer: Multiplan Commercial |
$548.80
|
| Rate for Payer: NAPHCARE Commercial |
$18.08
|
| Rate for Payer: Preferred Network Access Commercial |
$631.12
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$12.05
|
| Rate for Payer: Quartz Beloit One Network |
$336.14
|
| Rate for Payer: Quartz Commercial |
$445.90
|
| Rate for Payer: Quartz Medicare Advantage |
$12.05
|
| Rate for Payer: The Alliance Commercial |
$48.20
|
| Rate for Payer: United Healthcare Medicaid |
$12.05
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.05
|
| Rate for Payer: United Healthcare PPO |
$514.50
|
| Rate for Payer: WEA Trust Commercial |
$377.30
|
| Rate for Payer: Wellcare Medicare |
$12.05
|
| Rate for Payer: WMAP Medicaid |
$12.05
|
| Rate for Payer: WPS Commercial |
$508.12
|
|
|
.MOG Antibody Titer, Serum
|
Facility
|
IP
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$336.14 |
| Max. Negotiated Rate |
$631.12 |
| Rate for Payer: Aetna Commercial |
$617.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$363.58
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$631.12
|
| Rate for Payer: Health EOS Commercial |
$610.54
|
| Rate for Payer: HFN Commercial |
$631.12
|
| Rate for Payer: Multiplan Commercial |
$548.80
|
| Rate for Payer: NAPHCARE Commercial |
$411.60
|
| Rate for Payer: Preferred Network Access Commercial |
$631.12
|
| Rate for Payer: Quartz Beloit One Network |
$336.14
|
| Rate for Payer: Quartz Commercial |
$411.60
|
| Rate for Payer: WEA Trust Commercial |
$377.30
|
| Rate for Payer: WPS Commercial |
$508.12
|
|
|
.MOG Antibody Titer, Serum
|
Professional
|
Both
|
$686.00
|
|
|
Service Code
|
CPT 86362
|
| Hospital Charge Code |
6243839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$301.84 |
| Max. Negotiated Rate |
$651.70 |
| Rate for Payer: Aetna Commercial |
$651.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$589.96
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: Cigna Commercial |
$651.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$343.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$411.60
|
| Rate for Payer: Health EOS Commercial |
$624.26
|
| Rate for Payer: HFN Commercial |
$651.70
|
| Rate for Payer: Multiplan Commercial |
$548.80
|
| Rate for Payer: Preferred Network Access Commercial |
$651.70
|
| Rate for Payer: Quartz Beloit One Network |
$301.84
|
| Rate for Payer: Quartz Commercial |
$391.02
|
| Rate for Payer: The Alliance Commercial |
$343.00
|
| Rate for Payer: WEA Trust Commercial |
$377.30
|
| Rate for Payer: WPS Commercial |
$508.12
|
|
|
Molded inner boot L2280
|
Facility
|
OP
|
$1,581.00
|
|
|
Service Code
|
HCPCS L2280
|
| Hospital Charge Code |
4524749
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$316.33 |
| Max. Negotiated Rate |
$6,324.00 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Aetna Managed Medicare |
$442.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$316.33
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$316.33
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$316.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$884.73
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,185.75
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$1,027.65
|
| Rate for Payer: Quartz Medicare Advantage |
$948.60
|
| Rate for Payer: The Alliance Commercial |
$6,324.00
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
Molded inner boot L2280
|
Professional
|
Both
|
$1,581.00
|
|
|
Service Code
|
HCPCS L2280
|
| Hospital Charge Code |
4524749
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$695.64 |
| Max. Negotiated Rate |
$2,000.42 |
| Rate for Payer: Aetna Commercial |
$1,501.95
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,501.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$790.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$948.60
|
| Rate for Payer: Health EOS Commercial |
$1,438.71
|
| Rate for Payer: HFN Commercial |
$1,501.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,000.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$2,000.42
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,501.95
|
| Rate for Payer: Quartz Beloit One Network |
$695.64
|
| Rate for Payer: Quartz Commercial |
$901.17
|
| Rate for Payer: The Alliance Commercial |
$790.50
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
Molded inner boot L2280
|
Facility
|
IP
|
$1,581.00
|
|
|
Service Code
|
HCPCS L2280
|
| Hospital Charge Code |
4524749
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$774.69 |
| Max. Negotiated Rate |
$1,454.52 |
| Rate for Payer: Aetna Commercial |
$1,422.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,359.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$837.93
|
| Rate for Payer: Cash Price |
$474.30
|
| Rate for Payer: Cigna Commercial |
$1,454.52
|
| Rate for Payer: Health EOS Commercial |
$1,407.09
|
| Rate for Payer: HFN Commercial |
$1,454.52
|
| Rate for Payer: Multiplan Commercial |
$1,264.80
|
| Rate for Payer: NAPHCARE Commercial |
$948.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,454.52
|
| Rate for Payer: Quartz Beloit One Network |
$774.69
|
| Rate for Payer: Quartz Commercial |
$948.60
|
| Rate for Payer: WEA Trust Commercial |
$869.55
|
| Rate for Payer: WPS Commercial |
$1,171.05
|
|
|
Molecular Iso, Highly Purified
|
Facility
|
OP
|
$79.00
|
|
| Hospital Charge Code |
2776837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.12 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Aetna Managed Medicare |
$22.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$51.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$39.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$37.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$44.21
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.25
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$51.35
|
| Rate for Payer: Quartz Medicare Advantage |
$47.40
|
| Rate for Payer: The Alliance Commercial |
$316.00
|
| Rate for Payer: United Healthcare PPO |
$59.25
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Molecular Iso, Highly Purified
|
Facility
|
IP
|
$79.00
|
|
| Hospital Charge Code |
2776837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$72.68 |
| Rate for Payer: Aetna Commercial |
$71.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$41.87
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$72.68
|
| Rate for Payer: Health EOS Commercial |
$70.31
|
| Rate for Payer: HFN Commercial |
$72.68
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: NAPHCARE Commercial |
$47.40
|
| Rate for Payer: Preferred Network Access Commercial |
$72.68
|
| Rate for Payer: Quartz Beloit One Network |
$38.71
|
| Rate for Payer: Quartz Commercial |
$47.40
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Molecular Iso, Highly Purified
|
Professional
|
Both
|
$79.00
|
|
| Hospital Charge Code |
2776837
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$34.76 |
| Max. Negotiated Rate |
$75.05 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$67.94
|
| Rate for Payer: Cash Price |
$23.70
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$39.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$47.40
|
| Rate for Payer: Health EOS Commercial |
$71.89
|
| Rate for Payer: HFN Commercial |
$75.05
|
| Rate for Payer: Multiplan Commercial |
$63.20
|
| Rate for Payer: Preferred Network Access Commercial |
$75.05
|
| Rate for Payer: Quartz Beloit One Network |
$34.76
|
| Rate for Payer: Quartz Commercial |
$45.03
|
| Rate for Payer: The Alliance Commercial |
$39.50
|
| Rate for Payer: WEA Trust Commercial |
$43.45
|
| Rate for Payer: WPS Commercial |
$58.52
|
|
|
Molecular Nucleic Amp 2 Seq
|
Professional
|
Both
|
$285.00
|
|
| Hospital Charge Code |
2776838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$270.75 |
| Rate for Payer: Aetna Commercial |
$270.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$270.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$142.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$171.00
|
| Rate for Payer: Health EOS Commercial |
$259.35
|
| Rate for Payer: HFN Commercial |
$270.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: Preferred Network Access Commercial |
$270.75
|
| Rate for Payer: Quartz Beloit One Network |
$125.40
|
| Rate for Payer: Quartz Commercial |
$162.45
|
| Rate for Payer: The Alliance Commercial |
$142.50
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Molecular Nucleic Amp 2 Seq
|
Facility
|
OP
|
$285.00
|
|
| Hospital Charge Code |
2776838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$1,140.00 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Aetna Managed Medicare |
$79.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$185.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$142.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$136.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$159.49
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$213.75
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$185.25
|
| Rate for Payer: Quartz Medicare Advantage |
$171.00
|
| Rate for Payer: The Alliance Commercial |
$1,140.00
|
| Rate for Payer: United Healthcare PPO |
$213.75
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
|
Molecular Nucleic Amp 2 Seq
|
Facility
|
IP
|
$285.00
|
|
| Hospital Charge Code |
2776838
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.65 |
| Max. Negotiated Rate |
$262.20 |
| Rate for Payer: Aetna Commercial |
$256.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$245.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$151.05
|
| Rate for Payer: Cash Price |
$85.50
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Health EOS Commercial |
$253.65
|
| Rate for Payer: HFN Commercial |
$262.20
|
| Rate for Payer: Multiplan Commercial |
$228.00
|
| Rate for Payer: NAPHCARE Commercial |
$171.00
|
| Rate for Payer: Preferred Network Access Commercial |
$262.20
|
| Rate for Payer: Quartz Beloit One Network |
$139.65
|
| Rate for Payer: Quartz Commercial |
$171.00
|
| Rate for Payer: WEA Trust Commercial |
$156.75
|
| Rate for Payer: WPS Commercial |
$211.10
|
|
