|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.17 |
| Max. Negotiated Rate |
$490.36 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$319.80
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$394.79
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243862
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Aetna Managed Medicare |
$149.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$346.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.30
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$399.75
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$346.45
|
| Rate for Payer: Quartz Medicare Advantage |
$319.80
|
| Rate for Payer: The Alliance Commercial |
$2,132.00
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
Pneumococcal valent 20
|
Facility
|
IP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$261.17 |
| Max. Negotiated Rate |
$490.36 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$319.80
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$394.79
|
|
|
Pneumococcal valent 20
|
Facility
|
OP
|
$533.00
|
|
|
Service Code
|
CPT 90677
|
| Hospital Charge Code |
6243861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$149.24 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna Commercial |
$479.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$458.38
|
| Rate for Payer: Aetna Managed Medicare |
$149.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$346.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$266.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$255.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$282.49
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cash Price |
$159.90
|
| Rate for Payer: Cigna Commercial |
$490.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$394.30
|
| Rate for Payer: Health EOS Commercial |
$474.37
|
| Rate for Payer: HFN Commercial |
$490.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$399.75
|
| Rate for Payer: Multiplan Commercial |
$426.40
|
| Rate for Payer: NAPHCARE Commercial |
$319.80
|
| Rate for Payer: Preferred Network Access Commercial |
$490.36
|
| Rate for Payer: Quartz Beloit One Network |
$261.17
|
| Rate for Payer: Quartz Commercial |
$346.45
|
| Rate for Payer: Quartz Medicare Advantage |
$319.80
|
| Rate for Payer: The Alliance Commercial |
$2,132.00
|
| Rate for Payer: WEA Trust Commercial |
$293.15
|
| Rate for Payer: WPS Commercial |
$745.09
|
|
|
PNEUMOTHORAX WITH CC
|
Facility
|
IP
|
$28,954.00
|
|
|
Service Code
|
MSDRG 200
|
| Min. Negotiated Rate |
$10,414.94 |
| Max. Negotiated Rate |
$28,954.00 |
| Rate for Payer: Aetna Managed Medicare |
$10,414.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$22,658.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$17,367.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$16,500.24
|
| Rate for Payer: Anthem Medicare Advantage |
$10,414.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$10,414.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$10,414.94
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$10,414.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18,316.78
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$10,414.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$21,001.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$10,414.94
|
| Rate for Payer: Independent Care Health Plan Medicare |
$10,414.94
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$10,414.94
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$10,414.94
|
| Rate for Payer: NAPHCARE Commercial |
$15,622.41
|
| Rate for Payer: Quartz Medicare Advantage |
$10,414.94
|
| Rate for Payer: The Alliance Commercial |
$28,954.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$10,414.94
|
| Rate for Payer: United Healthcare PPO |
$16,349.94
|
| Rate for Payer: Wellcare Medicare |
$10,414.94
|
|
|
PNEUMOTHORAX WITH MCC
|
Facility
|
IP
|
$47,487.00
|
|
|
Service Code
|
MSDRG 199
|
| Min. Negotiated Rate |
$17,081.52 |
| Max. Negotiated Rate |
$47,487.00 |
| Rate for Payer: Aetna Managed Medicare |
$17,081.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$37,134.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$28,463.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$27,042.06
|
| Rate for Payer: Anthem Medicare Advantage |
$17,081.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$17,081.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$17,081.52
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$17,081.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30,019.16
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$17,081.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,594.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$17,081.52
|
| Rate for Payer: Independent Care Health Plan Medicare |
$17,081.52
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$17,081.52
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$17,081.52
|
| Rate for Payer: NAPHCARE Commercial |
$25,622.28
|
| Rate for Payer: Quartz Medicare Advantage |
$17,081.52
|
| Rate for Payer: The Alliance Commercial |
$47,487.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$17,081.52
|
| Rate for Payer: United Healthcare PPO |
$26,932.61
|
| Rate for Payer: Wellcare Medicare |
$17,081.52
|
|
|
PNEUMOTHORAX WITHOUT CC/MCC
|
Facility
|
IP
|
$19,093.00
|
|
|
Service Code
|
MSDRG 201
|
| Min. Negotiated Rate |
$6,867.90 |
| Max. Negotiated Rate |
$19,093.00 |
| Rate for Payer: Aetna Managed Medicare |
$6,867.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$14,895.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$11,417.51
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$10,847.38
|
| Rate for Payer: Anthem Medicare Advantage |
$6,867.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,867.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,867.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,867.90
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12,041.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,867.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,768.95
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,867.90
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,867.90
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,867.90
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,867.90
|
| Rate for Payer: NAPHCARE Commercial |
$10,301.85
|
| Rate for Payer: Quartz Medicare Advantage |
$6,867.90
|
| Rate for Payer: The Alliance Commercial |
$19,093.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,867.90
|
| Rate for Payer: United Healthcare PPO |
$10,719.30
|
| Rate for Payer: Wellcare Medicare |
$6,867.90
|
|
|
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: 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
|
| Rate for Payer: Wellcare Medicare |
$15,377.33
|
|
|
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
|
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 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, 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
|
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
|
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
|
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 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
|
|
