|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.21 |
| Max. Negotiated Rate |
$1,301.66 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Aetna Managed Medicare |
$155.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$415.74
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: NAPHCARE Commercial |
$332.59
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$360.31
|
| Rate for Payer: Quartz Medicare Advantage |
$332.59
|
| Rate for Payer: The Alliance Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.62 |
| Max. Negotiated Rate |
$509.97 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$332.59
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$410.57
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$155.21 |
| Max. Negotiated Rate |
$1,301.66 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Aetna Managed Medicare |
$155.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$360.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$277.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$266.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$410.07
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$415.74
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: NAPHCARE Commercial |
$332.59
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$360.31
|
| Rate for Payer: Quartz Medicare Advantage |
$332.59
|
| Rate for Payer: The Alliance Commercial |
$1,301.66
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$774.89
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.62 |
| Max. Negotiated Rate |
$509.97 |
| Rate for Payer: Aetna Commercial |
$498.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$476.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$293.79
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$509.97
|
| Rate for Payer: Health EOS Commercial |
$493.34
|
| Rate for Payer: HFN Commercial |
$509.97
|
| Rate for Payer: Multiplan Commercial |
$443.46
|
| Rate for Payer: Preferred Network Access Commercial |
$509.97
|
| Rate for Payer: Quartz Beloit One Network |
$271.62
|
| Rate for Payer: Quartz Commercial |
$332.59
|
| Rate for Payer: WEA Trust Commercial |
$304.88
|
| Rate for Payer: WPS Commercial |
$410.57
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$30,112.16
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$8,925.44 |
| Max. Negotiated Rate |
$30,112.16 |
| Rate for Payer: Aetna Managed Medicare |
$8,925.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$23,985.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$18,384.96
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$17,466.91
|
| Rate for Payer: Anthem Medicare Advantage |
$8,925.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$8,925.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$8,925.44
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$8,925.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$19,389.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$8,925.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,841.56
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$8,925.44
|
| Rate for Payer: Independent Care Health Plan Medicare |
$8,925.44
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$8,925.44
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$8,925.44
|
| Rate for Payer: NAPHCARE Commercial |
$13,388.15
|
| Rate for Payer: Quartz Medicare Advantage |
$8,925.44
|
| Rate for Payer: The Alliance Commercial |
$30,112.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$8,925.44
|
| Rate for Payer: United Healthcare PPO |
$17,003.94
|
| Rate for Payer: Wellcare Medicare |
$8,925.44
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$49,386.48
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$14,016.61 |
| Max. Negotiated Rate |
$49,386.48 |
| Rate for Payer: Aetna Managed Medicare |
$14,016.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$38,491.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29,503.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$28,030.00
|
| Rate for Payer: Anthem Medicare Advantage |
$14,016.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14,016.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14,016.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14,016.61
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$31,115.87
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14,016.61
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$35,978.75
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14,016.61
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14,016.61
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14,016.61
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14,016.61
|
| Rate for Payer: NAPHCARE Commercial |
$21,024.92
|
| Rate for Payer: Quartz Medicare Advantage |
$14,016.61
|
| Rate for Payer: The Alliance Commercial |
$49,386.48
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14,016.61
|
| Rate for Payer: United Healthcare PPO |
$28,009.91
|
| Rate for Payer: Wellcare Medicare |
$14,016.61
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$19,856.72
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$5,983.16 |
| Max. Negotiated Rate |
$19,856.72 |
| Rate for Payer: Aetna Managed Medicare |
$5,983.16
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$15,602.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,959.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,362.31
|
| Rate for Payer: Anthem Medicare Advantage |
$5,983.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$5,983.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$5,983.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$5,983.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,613.21
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$5,983.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$14,319.71
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$5,983.16
|
| Rate for Payer: Independent Care Health Plan Medicare |
$5,983.16
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$5,983.16
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$5,983.16
|
| Rate for Payer: NAPHCARE Commercial |
$8,974.74
|
| Rate for Payer: Quartz Medicare Advantage |
$5,983.16
|
| Rate for Payer: The Alliance Commercial |
$19,856.72
|
| Rate for Payer: United Healthcare Medicare Advantage |
$5,983.16
|
| Rate for Payer: United Healthcare PPO |
$11,148.07
|
| Rate for Payer: Wellcare Medicare |
$5,983.16
|
|
|
Pneumovax Supplies
|
Facility
|
IP
|
$53.00
|
|
| Hospital Charge Code |
3005585
|
| Min. Negotiated Rate |
$27.01 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$33.07
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
Pneumovax Supplies
|
Facility
|
OP
|
$53.00
|
|
| Hospital Charge Code |
3005585
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Aetna Commercial |
$49.61
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$47.40
|
| Rate for Payer: Aetna Managed Medicare |
$15.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$35.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$27.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$26.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$29.21
|
| Rate for Payer: Cash Price |
$15.90
|
| Rate for Payer: Cigna Commercial |
$50.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.85
|
| Rate for Payer: Health EOS Commercial |
$49.06
|
| Rate for Payer: HFN Commercial |
$50.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$41.34
|
| Rate for Payer: Multiplan Commercial |
$44.10
|
| Rate for Payer: NAPHCARE Commercial |
$33.07
|
| Rate for Payer: Preferred Network Access Commercial |
$50.71
|
| Rate for Payer: Quartz Beloit One Network |
$27.01
|
| Rate for Payer: Quartz Commercial |
$35.83
|
| Rate for Payer: Quartz Medicare Advantage |
$33.07
|
| Rate for Payer: The Alliance Commercial |
$27.56
|
| Rate for Payer: WEA Trust Commercial |
$30.32
|
| Rate for Payer: WPS Commercial |
$40.83
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC
|
Facility
|
IP
|
$44,458.96
|
|
|
Service Code
|
MSDRG 917
|
| Min. Negotiated Rate |
$12,517.91 |
| Max. Negotiated Rate |
$44,458.96 |
| Rate for Payer: Aetna Managed Medicare |
$12,517.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$34,221.23
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26,230.30
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24,920.50
|
| Rate for Payer: Anthem Medicare Advantage |
$12,517.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12,517.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12,517.91
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12,517.91
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$27,664.04
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12,517.91
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$32,364.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12,517.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12,517.91
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12,517.91
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12,517.91
|
| Rate for Payer: NAPHCARE Commercial |
$18,776.86
|
| Rate for Payer: Quartz Medicare Advantage |
$12,517.91
|
| Rate for Payer: The Alliance Commercial |
$44,458.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12,517.91
|
| Rate for Payer: United Healthcare PPO |
$25,196.45
|
| Rate for Payer: Wellcare Medicare |
$12,517.91
|
|
|
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC
|
Facility
|
IP
|
$24,136.32
|
|
|
Service Code
|
MSDRG 918
|
| Min. Negotiated Rate |
$7,070.63 |
| Max. Negotiated Rate |
$24,136.32 |
| Rate for Payer: Aetna Managed Medicare |
$7,070.63
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$18,701.24
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$14,334.35
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$13,618.56
|
| Rate for Payer: Anthem Medicare Advantage |
$7,070.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$7,070.63
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$7,070.63
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$7,070.63
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$15,117.86
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$7,070.63
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$17,459.05
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$7,070.63
|
| Rate for Payer: Independent Care Health Plan Medicare |
$7,070.63
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$7,070.63
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$7,070.63
|
| Rate for Payer: NAPHCARE Commercial |
$10,605.94
|
| Rate for Payer: Quartz Medicare Advantage |
$7,070.63
|
| Rate for Payer: The Alliance Commercial |
$24,136.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$7,070.63
|
| Rate for Payer: United Healthcare PPO |
$13,592.09
|
| Rate for Payer: Wellcare Medicare |
$7,070.63
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
OP
|
$131.03
|
|
|
Service Code
|
EAPG 00851
|
| Min. Negotiated Rate |
$125.99 |
| Max. Negotiated Rate |
$131.03 |
| Rate for Payer: Anthem Medicaid |
$125.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$125.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$125.99
|
| Rate for Payer: Dean Health Medicaid |
$125.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$125.99
|
| Rate for Payer: Managed Health Services Medicaid |
$131.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$125.99
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$125.99
|
| Rate for Payer: United Healthcare Medicaid |
$125.99
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$17,010.52
|
|
|
Service Code
|
APR-DRG 8124
|
| Min. Negotiated Rate |
$15,109.81 |
| Max. Negotiated Rate |
$17,010.52 |
| Rate for Payer: Anthem Medicaid |
$16,288.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$16,288.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$16,288.51
|
| Rate for Payer: Dean Health Medicaid |
$16,288.51
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15,109.81
|
| Rate for Payer: Managed Health Services Medicaid |
$17,010.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$16,288.51
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$16,288.51
|
| Rate for Payer: United Healthcare Medicaid |
$16,288.51
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$5,436.35
|
|
|
Service Code
|
APR-DRG 8122
|
| Min. Negotiated Rate |
$4,828.91 |
| Max. Negotiated Rate |
$5,436.35 |
| Rate for Payer: Anthem Medicaid |
$5,205.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,205.61
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,205.61
|
| Rate for Payer: Dean Health Medicaid |
$5,205.61
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$4,828.91
|
| Rate for Payer: Managed Health Services Medicaid |
$5,436.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,205.61
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,205.61
|
| Rate for Payer: United Healthcare Medicaid |
$5,205.61
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$3,682.69
|
|
|
Service Code
|
APR-DRG 8121
|
| Min. Negotiated Rate |
$3,271.20 |
| Max. Negotiated Rate |
$3,682.69 |
| Rate for Payer: Anthem Medicaid |
$3,526.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$3,526.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$3,526.38
|
| Rate for Payer: Dean Health Medicaid |
$3,526.38
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$3,271.20
|
| Rate for Payer: Managed Health Services Medicaid |
$3,682.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,526.38
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$3,526.38
|
| Rate for Payer: United Healthcare Medicaid |
$3,526.38
|
|
|
POISONING OF MEDICINAL AGENTS
|
Facility
|
IP
|
$8,680.63
|
|
|
Service Code
|
APR-DRG 8123
|
| Min. Negotiated Rate |
$7,710.67 |
| Max. Negotiated Rate |
$8,680.63 |
| Rate for Payer: Anthem Medicaid |
$8,312.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$8,312.18
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,312.18
|
| Rate for Payer: Dean Health Medicaid |
$8,312.18
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$7,710.67
|
| Rate for Payer: Managed Health Services Medicaid |
$8,680.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,312.18
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$8,312.18
|
| Rate for Payer: United Healthcare Medicaid |
$8,312.18
|
|
|
Poliovirus Antibody, Neutralization
|
Facility
|
IP
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$202.82 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$248.35
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Poliovirus Antibody, Neutralization
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$393.22 |
| Rate for Payer: Aetna Commercial |
$393.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$17.59
|
| Rate for Payer: Anthem Medicare Advantage |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.59
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$393.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$206.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.59
|
| Rate for Payer: Health EOS Commercial |
$376.67
|
| Rate for Payer: HFN Commercial |
$393.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.59
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$26.38
|
| Rate for Payer: Preferred Network Access Commercial |
$393.22
|
| Rate for Payer: Quartz Beloit One Network |
$182.12
|
| Rate for Payer: Quartz Commercial |
$235.93
|
| Rate for Payer: Quartz Medicare Advantage |
$17.59
|
| Rate for Payer: The Alliance Commercial |
$69.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.59
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: WPS Commercial |
$77.38
|
|
|
Poliovirus Antibody, Neutralization
|
Facility
|
OP
|
$398.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
983362
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$380.81 |
| Rate for Payer: Aetna Commercial |
$372.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.97
|
| Rate for Payer: Aetna Managed Medicare |
$17.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.19
|
| Rate for Payer: Anthem Medicare Advantage |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$219.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.59
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cash Price |
$119.40
|
| Rate for Payer: Cigna Commercial |
$380.81
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.64
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.59
|
| Rate for Payer: Health EOS Commercial |
$368.39
|
| Rate for Payer: HFN Commercial |
$380.81
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.59
|
| Rate for Payer: Multiplan Commercial |
$331.14
|
| Rate for Payer: NAPHCARE Commercial |
$26.38
|
| Rate for Payer: Preferred Network Access Commercial |
$380.81
|
| Rate for Payer: Quartz Beloit One Network |
$202.82
|
| Rate for Payer: Quartz Commercial |
$269.05
|
| Rate for Payer: Quartz Medicare Advantage |
$17.59
|
| Rate for Payer: The Alliance Commercial |
$70.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.59
|
| Rate for Payer: United Healthcare PPO |
$310.44
|
| Rate for Payer: WEA Trust Commercial |
$227.66
|
| Rate for Payer: Wellcare Medicare |
$17.59
|
| Rate for Payer: WPS Commercial |
$306.58
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.36 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$34.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$92.04
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$73.63
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$73.63
|
| Rate for Payer: The Alliance Commercial |
$61.36
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$46.52 |
| Max. Negotiated Rate |
$116.58 |
| Rate for Payer: Aetna Commercial |
$116.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$116.58
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$46.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$73.63
|
| Rate for Payer: Health EOS Commercial |
$111.68
|
| Rate for Payer: HFN Commercial |
$116.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$63.62
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$63.62
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$116.58
|
| Rate for Payer: Quartz Beloit One Network |
$54.00
|
| Rate for Payer: Quartz Commercial |
$69.95
|
| Rate for Payer: The Alliance Commercial |
$61.36
|
| Rate for Payer: United Healthcare Medicaid |
$46.52
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Poliovirus, IPV, SC/IM 90713
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 90713
|
| Hospital Charge Code |
3455571
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$73.63
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Poliovirus Type 2
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$17.59
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$30.78
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.19
|
| Rate for Payer: Anthem Medicare Advantage |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.59
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17.59
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$236.29
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17.59
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.42
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17.59
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.59
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17.59
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17.59
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$26.38
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$274.46
|
| Rate for Payer: Quartz Medicare Advantage |
$17.59
|
| Rate for Payer: The Alliance Commercial |
$70.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.59
|
| Rate for Payer: United Healthcare PPO |
$316.68
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: Wellcare Medicare |
$17.59
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Poliovirus Type 2
|
Facility
|
IP
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$206.90 |
| Max. Negotiated Rate |
$388.46 |
| Rate for Payer: Aetna Commercial |
$380.02
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$223.79
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$388.46
|
| Rate for Payer: Health EOS Commercial |
$375.79
|
| Rate for Payer: HFN Commercial |
$388.46
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: Preferred Network Access Commercial |
$388.46
|
| Rate for Payer: Quartz Beloit One Network |
$206.90
|
| Rate for Payer: Quartz Commercial |
$253.34
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$312.74
|
|
|
Poliovirus Type 2
|
Professional
|
Both
|
$406.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
2942973
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.59 |
| Max. Negotiated Rate |
$401.13 |
| Rate for Payer: Aetna Commercial |
$401.13
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$363.13
|
| Rate for Payer: Aetna Managed Medicare |
$17.59
|
| Rate for Payer: Anthem Medicare Advantage |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17.59
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cash Price |
$121.80
|
| Rate for Payer: Cigna Commercial |
$401.13
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$211.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$17.59
|
| Rate for Payer: Health EOS Commercial |
$384.24
|
| Rate for Payer: HFN Commercial |
$401.13
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$62.08
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$62.08
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17.59
|
| Rate for Payer: Multiplan Commercial |
$337.79
|
| Rate for Payer: NAPHCARE Commercial |
$26.38
|
| Rate for Payer: Preferred Network Access Commercial |
$401.13
|
| Rate for Payer: Quartz Beloit One Network |
$185.79
|
| Rate for Payer: Quartz Commercial |
$240.68
|
| Rate for Payer: Quartz Medicare Advantage |
$17.59
|
| Rate for Payer: The Alliance Commercial |
$69.47
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17.59
|
| Rate for Payer: WEA Trust Commercial |
$232.23
|
| Rate for Payer: WPS Commercial |
$77.38
|
|
