|
Pneumovax Supplies
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
3005585
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$212.00 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Aetna Managed Medicare |
$14.84
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$25.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$29.66
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39.75
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$34.45
|
| Rate for Payer: Quartz Medicare Advantage |
$31.80
|
| Rate for Payer: The Alliance Commercial |
$212.00
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
Pneumovax Supplies
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
3005585
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$48.76 |
| Rate for Payer: Aetna Commercial |
$47.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$45.58
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$28.09
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$48.76
|
| Rate for Payer: Health EOS Commercial |
$47.17
|
| Rate for Payer: HFN Commercial |
$48.76
|
| Rate for Payer: Multiplan Commercial |
$42.40
|
| Rate for Payer: NAPHCARE Commercial |
$31.80
|
| Rate for Payer: Preferred Network Access Commercial |
$48.76
|
| Rate for Payer: Quartz Beloit One Network |
$25.97
|
| Rate for Payer: Quartz Commercial |
$31.80
|
| Rate for Payer: WEA Trust Commercial |
$29.15
|
| Rate for Payer: WPS Commercial |
$39.26
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$42,749.00
|
|
|
Service Code
|
MSDRG 917
|
| Min. Negotiated Rate |
$15,377.33 |
| Max. Negotiated Rate |
$42,749.00 |
| Rate for Payer: Wellcare Medicare |
$15,377.33
|
| Rate for Payer: Aetna Managed Medicare |
$15,377.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33,568.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25,729.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,444.80
|
| Rate for Payer: Anthem Medicare Advantage |
$15,377.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,377.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,377.33
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,377.33
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,135.97
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,377.33
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$31,120.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,377.33
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,377.33
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,377.33
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,377.33
|
| Rate for Payer: NAPHCARE Commercial |
$23,066.00
|
| Rate for Payer: Quartz Medicare Advantage |
$15,377.33
|
| Rate for Payer: The Alliance Commercial |
$42,749.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,377.33
|
| Rate for Payer: United Healthcare PPO |
$24,227.36
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$23,208.00
|
|
|
Service Code
|
MSDRG 918
|
| Min. Negotiated Rate |
$8,348.31 |
| Max. Negotiated Rate |
$23,208.00 |
| Rate for Payer: Aetna Managed Medicare |
$8,348.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,042.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$13,829.66
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,139.08
|
| Rate for Payer: Anthem Medicare Advantage |
$8,348.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,348.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,348.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,348.31
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14,585.58
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,348.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$16,787.55
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,348.31
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,348.31
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,348.31
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,348.31
|
| Rate for Payer: NAPHCARE Commercial |
$12,522.46
|
| Rate for Payer: Quartz Medicare Advantage |
$8,348.31
|
| Rate for Payer: The Alliance Commercial |
$23,208.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,348.31
|
| Rate for Payer: United Healthcare PPO |
$13,069.32
|
| Rate for Payer: Wellcare Medicare |
$8,348.31
|
|
|
Poliovirus Antibody, Neutralization
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.69 |
| Max. Negotiated Rate |
$378.10 |
| Rate for Payer: Aetna Commercial |
$378.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$378.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$199.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$238.80
|
| Rate for Payer: Health EOS Commercial |
$362.18
|
| Rate for Payer: HFN Commercial |
$378.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.69
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: Preferred Network Access Commercial |
$378.10
|
| Rate for Payer: Quartz Beloit One Network |
$175.12
|
| Rate for Payer: Quartz Commercial |
$226.86
|
| Rate for Payer: The Alliance Commercial |
$199.00
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Poliovirus Antibody, Neutralization
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Aetna Managed Medicare |
$16.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.07
|
| Rate for Payer: Anthem Medicaid |
$17.47
|
| Rate for Payer: Anthem Medicare Advantage |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.91
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$222.72
|
| Rate for Payer: Dean Health Medicaid |
$17.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.91
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.91
|
| Rate for Payer: Managed Health Services Medicaid |
$18.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.91
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$25.36
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.47
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$258.70
|
| Rate for Payer: Quartz Medicare Advantage |
$16.91
|
| Rate for Payer: The Alliance Commercial |
$67.64
|
| Rate for Payer: United Healthcare Medicaid |
$17.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.91
|
| Rate for Payer: United Healthcare PPO |
$298.50
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: Wellcare Medicare |
$16.91
|
| Rate for Payer: WMAP Medicaid |
$17.47
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Poliovirus Antibody, Neutralization
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$195.02 |
| Max. Negotiated Rate |
$366.16 |
| Rate for Payer: Aetna Commercial |
$358.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$342.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$210.94
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$366.16
|
| Rate for Payer: Health EOS Commercial |
$354.22
|
| Rate for Payer: HFN Commercial |
$366.16
|
| Rate for Payer: Multiplan Commercial |
$318.40
|
| Rate for Payer: NAPHCARE Commercial |
$238.80
|
| Rate for Payer: Preferred Network Access Commercial |
$366.16
|
| Rate for Payer: Quartz Beloit One Network |
$195.02
|
| Rate for Payer: Quartz Commercial |
$238.80
|
| Rate for Payer: WEA Trust Commercial |
$218.90
|
| Rate for Payer: WPS Commercial |
$294.80
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.92 |
| Max. Negotiated Rate |
$112.10 |
| Rate for Payer: Aetna Commercial |
$112.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$55.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$70.80
|
| Rate for Payer: Health EOS Commercial |
$107.38
|
| Rate for Payer: HFN Commercial |
$112.10
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$61.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$61.17
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: Preferred Network Access Commercial |
$112.10
|
| Rate for Payer: Quartz Beloit One Network |
$51.92
|
| Rate for Payer: Quartz Commercial |
$67.26
|
| Rate for Payer: The Alliance Commercial |
$59.00
|
| Rate for Payer: United Healthcare Medicaid |
$55.64
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.82 |
| Max. Negotiated Rate |
$108.56 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.54
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: Health EOS Commercial |
$105.02
|
| Rate for Payer: HFN Commercial |
$108.56
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: NAPHCARE Commercial |
$70.80
|
| Rate for Payer: Preferred Network Access Commercial |
$108.56
|
| Rate for Payer: Quartz Beloit One Network |
$57.82
|
| Rate for Payer: Quartz Commercial |
$70.80
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.04 |
| Max. Negotiated Rate |
$472.00 |
| Rate for Payer: Aetna Commercial |
$106.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$101.48
|
| Rate for Payer: Aetna Managed Medicare |
$33.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$76.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$59.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$56.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$62.54
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$108.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$66.03
|
| Rate for Payer: Health EOS Commercial |
$105.02
|
| Rate for Payer: HFN Commercial |
$108.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$88.50
|
| Rate for Payer: Multiplan Commercial |
$94.40
|
| Rate for Payer: NAPHCARE Commercial |
$70.80
|
| Rate for Payer: Preferred Network Access Commercial |
$108.56
|
| Rate for Payer: Quartz Beloit One Network |
$57.82
|
| Rate for Payer: Quartz Commercial |
$76.70
|
| Rate for Payer: Quartz Medicare Advantage |
$70.80
|
| Rate for Payer: The Alliance Commercial |
$472.00
|
| Rate for Payer: WEA Trust Commercial |
$64.90
|
| Rate for Payer: WPS Commercial |
$87.40
|
|
|
Poliovirus Type 2
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$16.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.07
|
| Rate for Payer: Anthem Medicaid |
$17.47
|
| Rate for Payer: Anthem Medicare Advantage |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.91
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Dean Health Medicaid |
$17.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.91
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.91
|
| Rate for Payer: Managed Health Services Medicaid |
$18.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.91
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.47
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$16.91
|
| Rate for Payer: The Alliance Commercial |
$67.64
|
| Rate for Payer: United Healthcare Medicaid |
$17.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.91
|
| Rate for Payer: United Healthcare PPO |
$304.50
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: Wellcare Medicare |
$16.91
|
| Rate for Payer: WMAP Medicaid |
$17.47
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Poliovirus Type 2
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.69 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna Commercial |
$385.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$385.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.60
|
| Rate for Payer: Health EOS Commercial |
$369.46
|
| Rate for Payer: HFN Commercial |
$385.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.69
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: Preferred Network Access Commercial |
$385.70
|
| Rate for Payer: Quartz Beloit One Network |
$178.64
|
| Rate for Payer: Quartz Commercial |
$231.42
|
| Rate for Payer: The Alliance Commercial |
$203.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Poliovirus Type 2
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Poliovirus Type 3
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942974
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.69 |
| Max. Negotiated Rate |
$385.70 |
| Rate for Payer: Aetna Commercial |
$385.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$385.70
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$203.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$243.60
|
| Rate for Payer: Health EOS Commercial |
$369.46
|
| Rate for Payer: HFN Commercial |
$385.70
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$59.69
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$59.69
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: Preferred Network Access Commercial |
$385.70
|
| Rate for Payer: Quartz Beloit One Network |
$178.64
|
| Rate for Payer: Quartz Commercial |
$231.42
|
| Rate for Payer: The Alliance Commercial |
$203.00
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Poliovirus Type 3
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942974
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Aetna Managed Medicare |
$16.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$63.41
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.59
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28.07
|
| Rate for Payer: Anthem Medicaid |
$17.47
|
| Rate for Payer: Anthem Medicare Advantage |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16.91
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$17.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$227.20
|
| Rate for Payer: Dean Health Medicaid |
$17.47
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16.91
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16.91
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17.47
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16.91
|
| Rate for Payer: Managed Health Services Medicaid |
$18.17
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16.91
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$25.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$17.47
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$263.90
|
| Rate for Payer: Quartz Medicare Advantage |
$16.91
|
| Rate for Payer: The Alliance Commercial |
$67.64
|
| Rate for Payer: United Healthcare Medicaid |
$17.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16.91
|
| Rate for Payer: United Healthcare PPO |
$304.50
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: Wellcare Medicare |
$16.91
|
| Rate for Payer: WMAP Medicaid |
$17.47
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
Poliovirus Type 3
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942974
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$198.94 |
| Max. Negotiated Rate |
$373.52 |
| Rate for Payer: Aetna Commercial |
$365.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$349.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$215.18
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$373.52
|
| Rate for Payer: Health EOS Commercial |
$361.34
|
| Rate for Payer: HFN Commercial |
$373.52
|
| Rate for Payer: Multiplan Commercial |
$324.80
|
| Rate for Payer: NAPHCARE Commercial |
$243.60
|
| Rate for Payer: Preferred Network Access Commercial |
$373.52
|
| Rate for Payer: Quartz Beloit One Network |
$198.94
|
| Rate for Payer: Quartz Commercial |
$243.60
|
| Rate for Payer: WEA Trust Commercial |
$223.30
|
| Rate for Payer: WPS Commercial |
$300.72
|
|
|
POLYFORM SOLID 1/16 X 12 X 18 #A29213
|
Facility
|
IP
|
$1,248.00
|
|
| Hospital Charge Code |
2972143
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$611.52 |
| Max. Negotiated Rate |
$1,148.16 |
| Rate for Payer: Aetna Commercial |
$1,123.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,073.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$661.44
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$1,148.16
|
| Rate for Payer: Health EOS Commercial |
$1,110.72
|
| Rate for Payer: HFN Commercial |
$1,148.16
|
| Rate for Payer: Multiplan Commercial |
$998.40
|
| Rate for Payer: NAPHCARE Commercial |
$748.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,148.16
|
| Rate for Payer: Quartz Beloit One Network |
$611.52
|
| Rate for Payer: Quartz Commercial |
$748.80
|
| Rate for Payer: WEA Trust Commercial |
$686.40
|
| Rate for Payer: WPS Commercial |
$924.39
|
|
|
POLYFORM SOLID 1/16 X 12 X 18 #A29213
|
Facility
|
OP
|
$1,248.00
|
|
| Hospital Charge Code |
2972143
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$349.44 |
| Max. Negotiated Rate |
$4,992.00 |
| Rate for Payer: Aetna Commercial |
$1,123.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,073.28
|
| Rate for Payer: Aetna Managed Medicare |
$349.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$811.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$624.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$599.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$661.44
|
| Rate for Payer: Cash Price |
$374.40
|
| Rate for Payer: Cigna Commercial |
$1,148.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$698.38
|
| Rate for Payer: Health EOS Commercial |
$1,110.72
|
| Rate for Payer: HFN Commercial |
$1,148.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$936.00
|
| Rate for Payer: Multiplan Commercial |
$998.40
|
| Rate for Payer: NAPHCARE Commercial |
$748.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,148.16
|
| Rate for Payer: Quartz Beloit One Network |
$611.52
|
| Rate for Payer: Quartz Commercial |
$811.20
|
| Rate for Payer: Quartz Medicare Advantage |
$748.80
|
| Rate for Payer: The Alliance Commercial |
$4,992.00
|
| Rate for Payer: WEA Trust Commercial |
$686.40
|
| Rate for Payer: WPS Commercial |
$924.39
|
|
|
POLYFORM SPLINTINE 1/8 x 18" x 24" BEIGE #A292-02-4C4"
|
Facility
|
IP
|
$854.00
|
|
| Hospital Charge Code |
2970231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$418.46 |
| Max. Negotiated Rate |
$785.68 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$512.40
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
POLYFORM SPLINTINE 1/8 x 18" x 24" BEIGE #A292-02-4C4"
|
Facility
|
OP
|
$854.00
|
|
| Hospital Charge Code |
2970231
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$239.12 |
| Max. Negotiated Rate |
$3,416.00 |
| Rate for Payer: Aetna Commercial |
$768.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$734.44
|
| Rate for Payer: Aetna Managed Medicare |
$239.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$555.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$427.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$409.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$452.62
|
| Rate for Payer: Cash Price |
$256.20
|
| Rate for Payer: Cigna Commercial |
$785.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$477.90
|
| Rate for Payer: Health EOS Commercial |
$760.06
|
| Rate for Payer: HFN Commercial |
$785.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$640.50
|
| Rate for Payer: Multiplan Commercial |
$683.20
|
| Rate for Payer: NAPHCARE Commercial |
$512.40
|
| Rate for Payer: Preferred Network Access Commercial |
$785.68
|
| Rate for Payer: Quartz Beloit One Network |
$418.46
|
| Rate for Payer: Quartz Commercial |
$555.10
|
| Rate for Payer: Quartz Medicare Advantage |
$512.40
|
| Rate for Payer: The Alliance Commercial |
$3,416.00
|
| Rate for Payer: WEA Trust Commercial |
$469.70
|
| Rate for Payer: WPS Commercial |
$632.56
|
|
|
POLYFORM WRIST THUMB SPICA MED
|
Facility
|
OP
|
$193.00
|
|
| Hospital Charge Code |
2971257
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$772.00 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Aetna Managed Medicare |
$54.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$125.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$96.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$92.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$108.00
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$144.75
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$125.45
|
| Rate for Payer: Quartz Medicare Advantage |
$115.80
|
| Rate for Payer: The Alliance Commercial |
$772.00
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
POLYFORM WRIST THUMB SPICA MED
|
Facility
|
IP
|
$193.00
|
|
| Hospital Charge Code |
2971257
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$94.57 |
| Max. Negotiated Rate |
$177.56 |
| Rate for Payer: Aetna Commercial |
$173.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$165.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$102.29
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$177.56
|
| Rate for Payer: Health EOS Commercial |
$171.77
|
| Rate for Payer: HFN Commercial |
$177.56
|
| Rate for Payer: Multiplan Commercial |
$154.40
|
| Rate for Payer: NAPHCARE Commercial |
$115.80
|
| Rate for Payer: Preferred Network Access Commercial |
$177.56
|
| Rate for Payer: Quartz Beloit One Network |
$94.57
|
| Rate for Payer: Quartz Commercial |
$115.80
|
| Rate for Payer: WEA Trust Commercial |
$106.15
|
| Rate for Payer: WPS Commercial |
$142.96
|
|
|
POLY INSERT INFINITY EVERLAST CROSS-LINK SZ 1/1+ 8MM 33681108
|
Facility
|
IP
|
$14,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175039
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,105.00 |
| Max. Negotiated Rate |
$13,340.00 |
| Rate for Payer: Aetna Commercial |
$13,050.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,470.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,685.00
|
| Rate for Payer: Cash Price |
$4,350.00
|
| Rate for Payer: Cigna Commercial |
$13,340.00
|
| Rate for Payer: Health EOS Commercial |
$12,905.00
|
| Rate for Payer: HFN Commercial |
$13,340.00
|
| Rate for Payer: Multiplan Commercial |
$11,600.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,700.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,340.00
|
| Rate for Payer: Quartz Beloit One Network |
$7,105.00
|
| Rate for Payer: Quartz Commercial |
$8,700.00
|
| Rate for Payer: WEA Trust Commercial |
$7,975.00
|
| Rate for Payer: WPS Commercial |
$10,740.15
|
|
|
POLY INSERT INFINITY EVERLAST CROSS-LINK SZ 1/1+ 8MM 33681108
|
Facility
|
OP
|
$14,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
6175039
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,060.00 |
| Max. Negotiated Rate |
$58,000.00 |
| Rate for Payer: Aetna Commercial |
$13,050.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$12,470.00
|
| Rate for Payer: Aetna Managed Medicare |
$4,060.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$9,425.00
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$7,250.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$6,960.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$7,685.00
|
| Rate for Payer: Cash Price |
$4,350.00
|
| Rate for Payer: Cigna Commercial |
$13,340.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$8,114.20
|
| Rate for Payer: Health EOS Commercial |
$12,905.00
|
| Rate for Payer: HFN Commercial |
$13,340.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$10,875.00
|
| Rate for Payer: Multiplan Commercial |
$11,600.00
|
| Rate for Payer: NAPHCARE Commercial |
$8,700.00
|
| Rate for Payer: Preferred Network Access Commercial |
$13,340.00
|
| Rate for Payer: Quartz Beloit One Network |
$7,105.00
|
| Rate for Payer: Quartz Commercial |
$9,425.00
|
| Rate for Payer: Quartz Medicare Advantage |
$8,700.00
|
| Rate for Payer: The Alliance Commercial |
$58,000.00
|
| Rate for Payer: WEA Trust Commercial |
$7,975.00
|
| Rate for Payer: WPS Commercial |
$10,740.15
|
|
|
POLY INSERT INFINITY EVERLAST CROSS-LINK SZ 2+ H 10MM 33683210
|
Facility
|
IP
|
$18,871.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
5831726
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,246.79 |
| Max. Negotiated Rate |
$17,361.32 |
| Rate for Payer: Aetna Commercial |
$16,983.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$16,229.06
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$10,001.63
|
| Rate for Payer: Cash Price |
$5,661.30
|
| Rate for Payer: Cigna Commercial |
$17,361.32
|
| Rate for Payer: Health EOS Commercial |
$16,795.19
|
| Rate for Payer: HFN Commercial |
$17,361.32
|
| Rate for Payer: Multiplan Commercial |
$15,096.80
|
| Rate for Payer: NAPHCARE Commercial |
$11,322.60
|
| Rate for Payer: Preferred Network Access Commercial |
$17,361.32
|
| Rate for Payer: Quartz Beloit One Network |
$9,246.79
|
| Rate for Payer: Quartz Commercial |
$11,322.60
|
| Rate for Payer: WEA Trust Commercial |
$10,379.05
|
| Rate for Payer: WPS Commercial |
$13,977.75
|
|
