|
Serotype 68
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943012
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 8
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 8
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 8
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 9
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943004
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$59.96 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Aetna Managed Medicare |
$14.99
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.21
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$26.23
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.88
|
| Rate for Payer: Anthem Medicaid |
$15.49
|
| Rate for Payer: Anthem Medicare Advantage |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.99
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.99
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$15.49
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.87
|
| Rate for Payer: Dean Health Medicaid |
$15.49
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.99
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.76
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.99
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$15.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.99
|
| Rate for Payer: Managed Health Services Medicaid |
$16.11
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.99
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.99
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.48
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$15.49
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$14.95
|
| Rate for Payer: Quartz Medicare Advantage |
$14.99
|
| Rate for Payer: The Alliance Commercial |
$59.96
|
| Rate for Payer: United Healthcare Medicaid |
$15.49
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.99
|
| Rate for Payer: United Healthcare PPO |
$17.25
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: Wellcare Medicare |
$14.99
|
| Rate for Payer: WMAP Medicaid |
$15.49
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 9
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943004
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$52.91 |
| Rate for Payer: Aetna Commercial |
$21.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.85
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13.80
|
| Rate for Payer: Health EOS Commercial |
$20.93
|
| Rate for Payer: HFN Commercial |
$21.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$52.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$52.91
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: Preferred Network Access Commercial |
$21.85
|
| Rate for Payer: Quartz Beloit One Network |
$10.12
|
| Rate for Payer: Quartz Commercial |
$13.11
|
| Rate for Payer: The Alliance Commercial |
$11.50
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Serotype 9
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
2943004
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.27 |
| Max. Negotiated Rate |
$21.16 |
| Rate for Payer: Aetna Commercial |
$20.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$19.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$12.19
|
| Rate for Payer: Cash Price |
$6.90
|
| Rate for Payer: Cigna Commercial |
$21.16
|
| Rate for Payer: Health EOS Commercial |
$20.47
|
| Rate for Payer: HFN Commercial |
$21.16
|
| Rate for Payer: Multiplan Commercial |
$18.40
|
| Rate for Payer: NAPHCARE Commercial |
$13.80
|
| Rate for Payer: Preferred Network Access Commercial |
$21.16
|
| Rate for Payer: Quartz Beloit One Network |
$11.27
|
| Rate for Payer: Quartz Commercial |
$13.80
|
| Rate for Payer: WEA Trust Commercial |
$12.65
|
| Rate for Payer: WPS Commercial |
$17.04
|
|
|
Sertraline (Zoloft)
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
983402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.00 |
| Max. Negotiated Rate |
$166.25 |
| Rate for Payer: Aetna Commercial |
$166.25
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$166.25
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$87.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.00
|
| Rate for Payer: Health EOS Commercial |
$159.25
|
| Rate for Payer: HFN Commercial |
$166.25
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$80.06
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$80.06
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: Preferred Network Access Commercial |
$166.25
|
| Rate for Payer: Quartz Beloit One Network |
$77.00
|
| Rate for Payer: Quartz Commercial |
$99.75
|
| Rate for Payer: The Alliance Commercial |
$87.50
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
Sertraline (Zoloft)
|
Facility
|
IP
|
$175.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
983402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
Sertraline (Zoloft)
|
Facility
|
OP
|
$175.00
|
|
|
Service Code
|
CPT 80332
|
| Hospital Charge Code |
983402
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Aetna Managed Medicare |
$49.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.93
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$113.75
|
| Rate for Payer: Quartz Medicare Advantage |
$105.00
|
| Rate for Payer: The Alliance Commercial |
$700.00
|
| Rate for Payer: United Healthcare PPO |
$131.25
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
SET ANGEL CPRP PROCESSING ABS-10063
|
Facility
|
OP
|
$2,929.00
|
|
| Hospital Charge Code |
6217082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$820.12 |
| Max. Negotiated Rate |
$11,716.00 |
| Rate for Payer: Aetna Commercial |
$2,636.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,518.94
|
| Rate for Payer: Aetna Managed Medicare |
$820.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,903.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,464.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,405.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,552.37
|
| Rate for Payer: Cash Price |
$878.70
|
| Rate for Payer: Cigna Commercial |
$2,694.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,639.07
|
| Rate for Payer: Health EOS Commercial |
$2,606.81
|
| Rate for Payer: HFN Commercial |
$2,694.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,196.75
|
| Rate for Payer: Multiplan Commercial |
$2,343.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,757.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,694.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,435.21
|
| Rate for Payer: Quartz Commercial |
$1,903.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,757.40
|
| Rate for Payer: The Alliance Commercial |
$11,716.00
|
| Rate for Payer: WEA Trust Commercial |
$1,610.95
|
| Rate for Payer: WPS Commercial |
$2,169.51
|
|
|
SET ANGEL CPRP PROCESSING ABS-10063
|
Facility
|
IP
|
$2,929.00
|
|
| Hospital Charge Code |
6217082
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,435.21 |
| Max. Negotiated Rate |
$2,694.68 |
| Rate for Payer: Aetna Commercial |
$2,636.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,518.94
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,552.37
|
| Rate for Payer: Cash Price |
$878.70
|
| Rate for Payer: Cigna Commercial |
$2,694.68
|
| Rate for Payer: Health EOS Commercial |
$2,606.81
|
| Rate for Payer: HFN Commercial |
$2,694.68
|
| Rate for Payer: Multiplan Commercial |
$2,343.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,757.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,694.68
|
| Rate for Payer: Quartz Beloit One Network |
$1,435.21
|
| Rate for Payer: Quartz Commercial |
$1,757.40
|
| Rate for Payer: WEA Trust Commercial |
$1,610.95
|
| Rate for Payer: WPS Commercial |
$2,169.51
|
|
|
SET ASPIRATION/ANTICOAGULATION CELL SAVER A & A ASSEMBLY LINE 208 00208-00
|
Facility
|
OP
|
$526.00
|
|
| Hospital Charge Code |
2962912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$147.28 |
| Max. Negotiated Rate |
$2,104.00 |
| Rate for Payer: Aetna Commercial |
$473.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.36
|
| Rate for Payer: Aetna Managed Medicare |
$147.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$341.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$263.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$252.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.78
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$483.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$294.35
|
| Rate for Payer: Health EOS Commercial |
$468.14
|
| Rate for Payer: HFN Commercial |
$483.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$394.50
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: NAPHCARE Commercial |
$315.60
|
| Rate for Payer: Preferred Network Access Commercial |
$483.92
|
| Rate for Payer: Quartz Beloit One Network |
$257.74
|
| Rate for Payer: Quartz Commercial |
$341.90
|
| Rate for Payer: Quartz Medicare Advantage |
$315.60
|
| Rate for Payer: The Alliance Commercial |
$2,104.00
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
SET ASPIRATION/ANTICOAGULATION CELL SAVER A & A ASSEMBLY LINE 208 00208-00
|
Facility
|
IP
|
$526.00
|
|
| Hospital Charge Code |
2962912
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.74 |
| Max. Negotiated Rate |
$483.92 |
| Rate for Payer: Aetna Commercial |
$473.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$452.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$278.78
|
| Rate for Payer: Cash Price |
$157.80
|
| Rate for Payer: Cigna Commercial |
$483.92
|
| Rate for Payer: Health EOS Commercial |
$468.14
|
| Rate for Payer: HFN Commercial |
$483.92
|
| Rate for Payer: Multiplan Commercial |
$420.80
|
| Rate for Payer: NAPHCARE Commercial |
$315.60
|
| Rate for Payer: Preferred Network Access Commercial |
$483.92
|
| Rate for Payer: Quartz Beloit One Network |
$257.74
|
| Rate for Payer: Quartz Commercial |
$315.60
|
| Rate for Payer: WEA Trust Commercial |
$289.30
|
| Rate for Payer: WPS Commercial |
$389.61
|
|
|
SET BENGER LACRIMAL PROBE E4223
|
Facility
|
OP
|
$1,237.00
|
|
| Hospital Charge Code |
4520507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$346.36 |
| Max. Negotiated Rate |
$4,948.00 |
| Rate for Payer: Aetna Commercial |
$1,113.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,063.82
|
| Rate for Payer: Aetna Managed Medicare |
$346.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$804.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$618.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$593.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$655.61
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Cigna Commercial |
$1,138.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$692.23
|
| Rate for Payer: Health EOS Commercial |
$1,100.93
|
| Rate for Payer: HFN Commercial |
$1,138.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$927.75
|
| Rate for Payer: Multiplan Commercial |
$989.60
|
| Rate for Payer: NAPHCARE Commercial |
$742.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,138.04
|
| Rate for Payer: Quartz Beloit One Network |
$606.13
|
| Rate for Payer: Quartz Commercial |
$804.05
|
| Rate for Payer: Quartz Medicare Advantage |
$742.20
|
| Rate for Payer: The Alliance Commercial |
$4,948.00
|
| Rate for Payer: WEA Trust Commercial |
$680.35
|
| Rate for Payer: WPS Commercial |
$916.25
|
|
|
SET BENGER LACRIMAL PROBE E4223
|
Facility
|
IP
|
$1,237.00
|
|
| Hospital Charge Code |
4520507
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$606.13 |
| Max. Negotiated Rate |
$1,138.04 |
| Rate for Payer: Aetna Commercial |
$1,113.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,063.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$655.61
|
| Rate for Payer: Cash Price |
$371.10
|
| Rate for Payer: Cigna Commercial |
$1,138.04
|
| Rate for Payer: Health EOS Commercial |
$1,100.93
|
| Rate for Payer: HFN Commercial |
$1,138.04
|
| Rate for Payer: Multiplan Commercial |
$989.60
|
| Rate for Payer: NAPHCARE Commercial |
$742.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,138.04
|
| Rate for Payer: Quartz Beloit One Network |
$606.13
|
| Rate for Payer: Quartz Commercial |
$742.20
|
| Rate for Payer: WEA Trust Commercial |
$680.35
|
| Rate for Payer: WPS Commercial |
$916.25
|
|
|
SET BLOOD COLLECTION 25G X .75 SAFETY"
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
2963558
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Aetna Managed Medicare |
$10.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$24.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$19.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$21.26
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$28.50
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$24.70
|
| Rate for Payer: Quartz Medicare Advantage |
$22.80
|
| Rate for Payer: The Alliance Commercial |
$152.00
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
SET BLOOD COLLECTION 25G X .75 SAFETY"
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
2963558
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$34.96 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$32.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$20.14
|
| Rate for Payer: Cash Price |
$11.40
|
| Rate for Payer: Cigna Commercial |
$34.96
|
| Rate for Payer: Health EOS Commercial |
$33.82
|
| Rate for Payer: HFN Commercial |
$34.96
|
| Rate for Payer: Multiplan Commercial |
$30.40
|
| Rate for Payer: NAPHCARE Commercial |
$22.80
|
| Rate for Payer: Preferred Network Access Commercial |
$34.96
|
| Rate for Payer: Quartz Beloit One Network |
$18.62
|
| Rate for Payer: Quartz Commercial |
$22.80
|
| Rate for Payer: WEA Trust Commercial |
$20.90
|
| Rate for Payer: WPS Commercial |
$28.15
|
|
|
SET BORE SM EXTENSION 473042
|
Facility
|
IP
|
$114.00
|
|
| Hospital Charge Code |
4595219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.86 |
| Max. Negotiated Rate |
$104.88 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$68.40
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
SET BORE SM EXTENSION 473042
|
Facility
|
OP
|
$114.00
|
|
| Hospital Charge Code |
4595219
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$102.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.04
|
| Rate for Payer: Aetna Managed Medicare |
$31.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$54.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.42
|
| Rate for Payer: Cash Price |
$34.20
|
| Rate for Payer: Cigna Commercial |
$104.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$63.79
|
| Rate for Payer: Health EOS Commercial |
$101.46
|
| Rate for Payer: HFN Commercial |
$104.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$85.50
|
| Rate for Payer: Multiplan Commercial |
$91.20
|
| Rate for Payer: NAPHCARE Commercial |
$68.40
|
| Rate for Payer: Preferred Network Access Commercial |
$104.88
|
| Rate for Payer: Quartz Beloit One Network |
$55.86
|
| Rate for Payer: Quartz Commercial |
$74.10
|
| Rate for Payer: Quartz Medicare Advantage |
$68.40
|
| Rate for Payer: The Alliance Commercial |
$456.00
|
| Rate for Payer: WEA Trust Commercial |
$62.70
|
| Rate for Payer: WPS Commercial |
$84.44
|
|
|
SET CRICOTHYROTOMY CATH. 3.5MM
|
Facility
|
IP
|
$1,707.00
|
|
| Hospital Charge Code |
2963099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$836.43 |
| Max. Negotiated Rate |
$1,570.44 |
| Rate for Payer: Aetna Commercial |
$1,536.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.71
|
| Rate for Payer: Cash Price |
$512.10
|
| Rate for Payer: Cigna Commercial |
$1,570.44
|
| Rate for Payer: Health EOS Commercial |
$1,519.23
|
| Rate for Payer: HFN Commercial |
$1,570.44
|
| Rate for Payer: Multiplan Commercial |
$1,365.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,570.44
|
| Rate for Payer: Quartz Beloit One Network |
$836.43
|
| Rate for Payer: Quartz Commercial |
$1,024.20
|
| Rate for Payer: WEA Trust Commercial |
$938.85
|
| Rate for Payer: WPS Commercial |
$1,264.37
|
|
|
SET CRICOTHYROTOMY CATH. 3.5MM
|
Facility
|
OP
|
$1,707.00
|
|
| Hospital Charge Code |
2963099
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$477.96 |
| Max. Negotiated Rate |
$6,828.00 |
| Rate for Payer: Aetna Commercial |
$1,536.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,468.02
|
| Rate for Payer: Aetna Managed Medicare |
$477.96
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,109.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$853.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$819.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$904.71
|
| Rate for Payer: Cash Price |
$512.10
|
| Rate for Payer: Cigna Commercial |
$1,570.44
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$955.24
|
| Rate for Payer: Health EOS Commercial |
$1,519.23
|
| Rate for Payer: HFN Commercial |
$1,570.44
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,280.25
|
| Rate for Payer: Multiplan Commercial |
$1,365.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,024.20
|
| Rate for Payer: Preferred Network Access Commercial |
$1,570.44
|
| Rate for Payer: Quartz Beloit One Network |
$836.43
|
| Rate for Payer: Quartz Commercial |
$1,109.55
|
| Rate for Payer: Quartz Medicare Advantage |
$1,024.20
|
| Rate for Payer: The Alliance Commercial |
$6,828.00
|
| Rate for Payer: WEA Trust Commercial |
$938.85
|
| Rate for Payer: WPS Commercial |
$1,264.37
|
|
|
SET CRICOTHYROTOMY CATH. 6MM
|
Facility
|
IP
|
$1,904.00
|
|
| Hospital Charge Code |
2963116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$932.96 |
| Max. Negotiated Rate |
$1,751.68 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,142.40
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
SET CRICOTHYROTOMY CATH. 6MM
|
Facility
|
OP
|
$1,904.00
|
|
| Hospital Charge Code |
2963116
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$533.12 |
| Max. Negotiated Rate |
$7,616.00 |
| Rate for Payer: Aetna Commercial |
$1,713.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,637.44
|
| Rate for Payer: Aetna Managed Medicare |
$533.12
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.60
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$952.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,009.12
|
| Rate for Payer: Cash Price |
$571.20
|
| Rate for Payer: Cigna Commercial |
$1,751.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.48
|
| Rate for Payer: Health EOS Commercial |
$1,694.56
|
| Rate for Payer: HFN Commercial |
$1,751.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,428.00
|
| Rate for Payer: Multiplan Commercial |
$1,523.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,142.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,751.68
|
| Rate for Payer: Quartz Beloit One Network |
$932.96
|
| Rate for Payer: Quartz Commercial |
$1,237.60
|
| Rate for Payer: Quartz Medicare Advantage |
$1,142.40
|
| Rate for Payer: The Alliance Commercial |
$7,616.00
|
| Rate for Payer: WEA Trust Commercial |
$1,047.20
|
| Rate for Payer: WPS Commercial |
$1,410.29
|
|
|
SET CYSTO IRRIGATION DYND19120
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS A4355
|
| Hospital Charge Code |
2962814
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.20 |
| Max. Negotiated Rate |
$460.00 |
| Rate for Payer: Aetna Commercial |
$103.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$98.90
|
| Rate for Payer: Aetna Managed Medicare |
$32.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$74.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$57.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$55.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$60.95
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$105.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$64.35
|
| Rate for Payer: Health EOS Commercial |
$102.35
|
| Rate for Payer: HFN Commercial |
$105.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$92.00
|
| Rate for Payer: NAPHCARE Commercial |
$69.00
|
| Rate for Payer: Preferred Network Access Commercial |
$105.80
|
| Rate for Payer: Quartz Beloit One Network |
$56.35
|
| Rate for Payer: Quartz Commercial |
$74.75
|
| Rate for Payer: Quartz Medicare Advantage |
$69.00
|
| Rate for Payer: The Alliance Commercial |
$460.00
|
| Rate for Payer: WEA Trust Commercial |
$63.25
|
| Rate for Payer: WPS Commercial |
$85.18
|
|
